RE: SSM from Canadian Emergency News

September 26, 2005

My partner and I are EMS consultants and we never recommend SSM. We always

point out the things that Dr. Bledsoe has stated, and attempt to undo the

damage that has been done by folks like Stout and his followers.

Gene Gandy

HillGandy Associates

EMS Consultants

> why I ask if it has been tried and tried in EMS do " consultants " continue

> to push the idea that SSM is the way? If these people were true statisticians

> they would know by now that this has failed time and time again.

>

> SSM from Canadian Emergency News

>

> The Fallacy of System Status Management (SSM)

>

> By Dr. E. Bledsoe

>

> The concept of System Status Management (SSM) was introduced

> to

> EMS in the May, 1983 issue of JEMS magazine. <outbind://38/#_edn1> [1]

> Stout

> was a research fellow at the University of Oklahoma in the late 1970s and

> a

> part of a team of economists and behavioral scientists that was organized

> to

> perform a theoretical analysis of the prehospital care " industry. " The

> team,

> known as the Health Policy Research Team, was funded by a grant from the

> Kerr Foundation. The team was headed by Stout. However, Stout subsequently

> left the university and founded an EMS consulting firm known as The Fourth

> Party. The Fourth Party specialized in the development of " high

> performance

> EMS systems " which meant they primarily used the Public Utility Model

> (PUM)

> as a template for system design. Approximately 15 U.S. EMS systems adopted

> the PUM. However, there have been no new PUMs developed in the last 20

> years

> and several of the established PUMs have suffered significant financial

> problems, high employee turnover, and similar issues. <outbind://38/#_edn2>

>

> [2]

>

> The SSM theory was first applied to EMS operations in Tulsa

> and

> Oklahoma City and later to several other Midwestern U.S. cities. Later,

> several of the various components of " high performance EMS " were adopted

> by

> systems that do not use the PUM. Several EMS systems in Canada have

> adopted

> SSM. It is important to point out that virtually all EMS systems and fire

> departments have had deployment plans. That is, when several units in a

> particular part of town are busy, other units are routed toward that part

> of

> town in order to decrease response times in case a call is received. Stout

> took this one step further. He wrote, " System status management refers to

> the formal or informal systems protocols and procedures which determine

> where the remaining ambulances will be when the next call comes in. "

> Stout

> recommended that one look at both historic and geographic data in order to

> predict where the next ambulance call may occur and direct ambulances in

> that direction. He suggested that EMS follows a " weekly cycle " and SSM

> should target that. Typically, 20 weeks of historic and geographic call

> data

> are kept in the computer-aided dispatch (CAD) system. From this,

> ambulances

> are placed based upon perceived need. The foundation of SSM is to develop

> a

> system status management plan.

>

> In 1986, Stout further detailed the use of CAD to enhance SSM.

> <outbind://38/#_edn3> [3] He stated, " My own opinion is that it becomes

> impossible to reliably handle SSM controls on a manual basis when your pea

> k

> load coverage exceeds seven or eight units. After that level, you need

> automation. "

>

> The advantages of SSM, as detailed by Stout, are:

>

> * Reduce non-emergency service delays

> * Equalize service among neighborhoods

> * Safely " make room " for non-emergency service production at low

> marginal cost

> * Reduce the use of on-call crews

> * Reduce the frequency of post-to-post moves

> * Equalize workloads among crews

> * Differentiate workloads of 24-hour crews from those of short shift

> crews.

> * Furnish better mutual aid service

> * Reduce use of mutual aid service

> * Cut overtime

> * Employee schedules more convenient to crews

> * Battle " cream-skimmers " working your market.

> * Cut production costs without hurting response time performance.

>

> In 1989, in response to criticism of SSM, Stout published another article

> in

> JEMS that supposedly debunked the 6 " so-called " myths of SSM.

> <outbind://38/#_edn4> [4]

>

> Fallacies

>

> With this introduction in mind, let's look at the fallacies of this plan.

>

> 1. No peer review publications. System status management was

> introduced

> in several issues of the Journal of Emergency Medical Services (JEMS).

> JEMS

> is a U.S. EMS trade magazine and not peer-reviewed. A literature search

> failed to identify any scientific paper detailing the effectiveness of

> SSM.

> Several papers are written in scientific journals-but each is written

> under

> the premise that SSM is a proven system. <outbind://38/#_edn5> [5],

> <outbind://38/#_edn6> [6] The burden of proof for a particular system or

> practice is upon the proponents of such a system. With SSM, many in EMS

> adopted it at face value because it " intuitively " made sense or they were

> dazzled by suggested cost savings and improvements in efficiency.

> 2. Calls are predictable. It is intuitive that there will be more EMS

> calls during times when there are more cars on the road. And, it is

> intuitive that accidents are more likely to occur on roads. Thus, it makes

> sense to have an adequate number of ambulances during drive time and to

> position those ambulances where they can rapidly access major

> thoroughfares.

> Now, this is where SSM falls apart. It is statistically impossible, with

> ANY

> degree of accuracy, to predict where an ambulance call will occur (either

> geographically or temporally) based upon 20 weeks of data. In discussing

> the

> concept of SSM with 2 statisticians who hold doctorates, I asked how many

> weeks of data would be necessary to make an EMS call (or trend) prediction

> with any degree of scientific accuracy for a city the size of Fort Worth

> Texas (approximately 800,000 people). One said 20 years and the other said

> 100 years. Both pointed to the inability of weather service to accurately

> predict the high temperature for a day. With over 100 years of data,

> meteorologists can predict, with limited scientific accuracy, what the

> high

> temperature for a given day will be. Despite this, they are often wrong.

> And, they are dealing with a single variable!

>

> The ability to predict where and when a call will occur is

> nothing more than the statistical term probability. By definition,

> probability is a numerical quantity that expresses the likelihood of an

> event and is written as:

>

> Pr {E}

>

> The probability Pr {E} is always a number between 0 and 1. For example,

> each

> time you toss a coin in the air it will fall heads or tails. If the coin

> is

> not bent, it will equally fall heads and tails:

>

> However, with SSM we are using multiple random variables. The mean of a

> discrete random variable (Y) is defined as:

>

> where all the y1's are the values that the variable takes on and the

> sum is taken over all possible values. The mean of a random variable is

> also known as the expected value and is often written as E(Y) (thus

> E(Y)

> = .)

>

> Consider trying to predict where a call will occur in Fort

> Worth, Texas. Say, for example, there are 200,000 addresses in the CAD.

> There are 1,440 minutes in a day. Thus, what are the chances of making a

> calculation with this many variables that is nothing more than chance? The

> answer? Virtually impossible-even with a super computer. Furthermore, if

> an

> EMS system ever gathered enough historic and geographic data to make a

> prediction as to call time a location, the socioeconomic status of the

> city

> will have changed making the predictions irrelevant.

>

> 3. Reduce non-emergency service delays. In theory, SSM is designed to

> reduce non-emergent delays. However, in most systems that use SSM,

> non-emergency delays remain a major problem. The categorization of calls

> (and the low priority of non-emergency calls) continues to bump

> non-emergency calls down while ambulances are posted to perceived need

> areas

> in the event an emergency call comes in.

>

> 4. Equalize service among neighborhoods. This is one of the biggest

> fallacies of SSM. We know, from empiric studies, that ambulance demand is

> higher in low socioeconomic areas and areas where large numbers of elderly

> people live (also often low socioeconomic areas). Cadigan and Bugarin

> found

> that differences in EMS demand are related to median income, percentage of

> the population more than 65 years of age, and percentage of people living

> below the poverty level. Increased EMS demand was found in areas where a

> significant percentage of the population is greater than 65 years of age

> or

> living below the poverty level. <outbind://38/#_edn7> [7] Thus, if SSM is

> working as it should (diverting ambulances from predicted low call volume

> areas to predicted high call volume areas), ambulances should be routinely

> diverted from the younger and more affluent areas of town to regions where

> the population is older and living below the poverty level. This, in fact,

> discriminates against parts of town that use EMS infrequently (and parts

> of

> town where the majority of taxes are paid).

>

> 5. Safely " make room " for non-emergency service production at low

> marginal cost. In the U.S., reimbursement is better (and more reliable)

> for

> non-emergency calls than emergency calls. However, in Canada, the

> differences in reimbursement are much less. Thus, SSM will not

> significantly

> benefit Canadian EMS systems from this perspective.

> 6. Reduce the use of on-call crews. Here, Stout is being honest. SSM

> is

> designed to reduce staffing. More importantly, it is designed to reduce

> costs as posting ambulances from a central facility decreases the need for

> brick and mortar stations-a significant cost for EMS systems. This is

> particularly true for " for-profit " EMS systems in the U.S. that must also

> pay property taxes (ad-valorem) on brick and mortar stations (governmental

> agencies do not have to pay taxes). Looking beyond the smoke and mirrors,

> one of the main purposes of SSM is to get as much work as possible out of

> a

> subset of employees before bringing in back-up personnel which may cost

> overtime.

> 7. Reduce the frequency of post-to-post moves. Another fallacy! It is

> not uncommon for an EMS unit to travel 100-200 miles in a day and only run

> 3

> calls-the remainder of the time moving from post-to-post. Remember, the

> CAD

> cares not about the crew-only the location of the ambulance.

> 8. Equalize workloads among crews. If the system is not busy, SSM can

> equalize the workload. However, if the system is busy, EMS units that are

> busy stay busy. In many cities, hospitals are located downtown or in lower

> socioeconomic areas. Thus, every time a crew takes a patient to the

> hospital, they are closer to the next call when they clear the hospital.

> This is why some crews will run emergency calls all day while another crew

> does nothing but posts.

> 9. Differentiate workloads of 24-hour crews from those of short shift

> crews. This sounds good on paper. But, the CAD does not know a 24-hour

> crew

> from another crew. It simply selects the next closest ambulance

> regardless.

> 10. Furnish better mutual aid service. In the PUM, EMS systems are

> often

> financially penalized when they provide mutual aid-especially if it delays

> response times in their primary response area. Thus, systems using SSM are

> often reluctant to enter into mutual aid agreements with surrounding

> agencies. When this does occur, mutual aid is provided to the system using

> SSM more than system ambulances responding to neighboring communities

> (which

> are often suburbs).

> 11. Reduce use of mutual aid service. This is a non-sequitur. Stout

> wants to furnish better mutual aid service and, at the same time, reduce

> the

> use of mutual aid. The latter is the real preference as using mutual aid

> may

> be accompanied by a financial penalty. Thus, in many SSM systems, when the

> system reaches capacity-ambulances are asked to use lights and sirens to

> decrease transport times instead of asking for help from neighboring

> agencies.

> 12. Cut overtime. This is absolutely a goal. Cutting overtime cuts

> expenses. However, it fails to take into consideration other factors.

> Using

> a weekly cycle, the EMS system using SSM may drop the number of ambulances

> on a Saturday. But, if the weather on that day happens to turn bad, or a

> localized disaster occurs, personnel must be called in.

> 13. Employee schedules more convenient to crews. I dare you to find

> an

> SSM system where people like the schedules. Sometimes the schedules are

> contrary to the normal circadian rhythm and, other times, the schedule is

> so

> awkward that people have trouble adapting. For example, going in at 7:00

> PM

> and working until 3:00 AM is more stressful than typical 12-hour or 8-hour

> shifts.

> 14. Battle " cream-skimmers " working your market. This is more a U.S.

> phenomenon, But, as stated above, part of the goal of SSM is to keep " for

> profit " ambulances out of the non-emergency transfer market. In fact, most

> PUMs have exclusivity agreements where they are the only service used to

> transport any patient within the city. This leads to the problems with

> non-emergency patients already described.

> 15. Cut production costs without hurting response time performance.

> There is some truth here. Production costs are cut at the expense of

> personnel! Ambulances and personnel are relatively inexpensive (compared

> to

> brick and mortar stations). Thus, push personnel and the ambulances to

> their

> maximum-after all, they are expendable. It is no wonder that the incidence

> of back pain in Ottawa increased by 71% following the implementation of

> SSM.

> <outbind://38/#_edn8> [8] Furthermore, EMS personnel in Ottawa spent 51%

> of

> their time roaming.

>

> Summary

>

> Thus, to my colleagues in Canada, do not make the same mistake we have in

> the States. SSM is a bad idea and totally based on pseudoscience. It is

> promoted by consultants and experts who have never taken a look at the

> science (or lack thereof) behind the practice. Canada has a good EMS

> system

> and low employee turnover. SSM will drive away personnel in Canada as it

> has

> in the U.S. Consider this, why has not a single major fire department in

> the

> US (including those who operate the ambulance service) adopted SSM? The

> reason is obvious. They looked and did not find the system sound. Don't be

> dazzled by statistics and buzz words. The consultants will tell you that

> once SSM was instituted in Tulsa, Oklahoma, the response time decreased

> from

> 6 minutes 46 seconds to 6 minutes 9 seconds (statitistically

> significant-but

> not clinically significant). At the same time, maintenance costs increased

> by 38% and miles travelled increased by 19%. <outbind://38/#_edn9> [9]

> They

> always seem to leave that last part out. <outbind://38/#_edn10> [10]

>

> References

>

> _____

>

> <outbind://38/#_ednref1> [1] Stout JL. System Status Management: The

> Strategy of Ambulance Placement. Journal of Emergency Medical Services

> (JEMS. 1983;9(5):22-32,

>

> <outbind://38/#_ednref2> [2] Stout J. The public utility model, Part I:

> Measuring your system. Journal of Emergency Medical Services (JEMS).

> 1980;6(3):22-25.

>

> <outbind://38/#_ednref3> [3] Stout JL. Computer-Aided What? Journal of

> Emergency Medical Services (JEMS). 1986;12(12):89-94.

>

> <outbind://38/#_ednref4> [4] Stout JL. System Status Management: The Fact

> Is, It's Everywhere. Journal of Emergency Medical Services (JEMS).

> 1989;14(4):65-71

>

> <outbind://38/#_ednref5> [5] Stout JL, Pepe PE, Mosseso VN Jr. All

> advanced

> life support versus tiered response ambulances. Prehospital Emergency

> Care.2000:4(1):1-6

>

> <outbind://38/#_ednref6> [6] Hauswald M, Drake C. Innovations in emergency

> medical services. Emergency Medicine Clinics of North America.

> 1990;8(1):135-144

>

> <outbind://38/#_ednref7> [7] Cadigan RT, Bugarin CE. Predicting demand for

> emergency ambulance service. ls of Emergency Medicine.

> 1989;18:618-621.

>

> <outbind://38/#_ednref8> [8] Morneau PM, Stothart JP. My aching back: Th

> effects of system status management and ambulance design on EMS personnel.

> Journal of Emergency Medical Services (JEMS);1999:24(8):36-40

>

> <outbind://38/#_ednref9> [9] Hough TH. A View from the Street: System

> Status Management. Journal of Emergency Medical Services (JEMS).

> 1986;12(12):48-50

>

> <outbind://38/#_ednref10> [10] Bledsoe BE. EMS Myth # 7: System Status

> Management lowers response time and enhances patient care. Emergency

> Medical

> Services. 2003;32(9):158-159

>

September 26, 2005

why I ask if it has been tried and tried in EMS do " consultants " continue to

push the idea that SSM is the way? If these people were true statisticians they

would know by now that this has failed time and time again.

SSM from Canadian Emergency News

The Fallacy of System Status Management (SSM)

By Dr. E. Bledsoe

The concept of System Status Management (SSM) was introduced to

EMS in the May, 1983 issue of JEMS magazine. <outbind://38/#_edn1> [1] Stout

was a research fellow at the University of Oklahoma in the late 1970s and a

part of a team of economists and behavioral scientists that was organized to

perform a theoretical analysis of the prehospital care " industry. " The team,

known as the Health Policy Research Team, was funded by a grant from the

Kerr Foundation. The team was headed by Stout. However, Stout subsequently

left the university and founded an EMS consulting firm known as The Fourth

Party. The Fourth Party specialized in the development of " high performance

EMS systems " which meant they primarily used the Public Utility Model (PUM)

as a template for system design. Approximately 15 U.S. EMS systems adopted

the PUM. However, there have been no new PUMs developed in the last 20 years

and several of the established PUMs have suffered significant financial

problems, high employee turnover, and similar issues. <outbind://38/#_edn2>

[2]

The SSM theory was first applied to EMS operations in Tulsa and

Oklahoma City and later to several other Midwestern U.S. cities. Later,

several of the various components of " high performance EMS " were adopted by

systems that do not use the PUM. Several EMS systems in Canada have adopted

SSM. It is important to point out that virtually all EMS systems and fire

departments have had deployment plans. That is, when several units in a

particular part of town are busy, other units are routed toward that part of

town in order to decrease response times in case a call is received. Stout

took this one step further. He wrote, " System status management refers to

the formal or informal systems protocols and procedures which determine

where the remaining ambulances will be when the next call comes in. " Stout

recommended that one look at both historic and geographic data in order to

predict where the next ambulance call may occur and direct ambulances in

that direction. He suggested that EMS follows a " weekly cycle " and SSM

should target that. Typically, 20 weeks of historic and geographic call data

are kept in the computer-aided dispatch (CAD) system. From this, ambulances

are placed based upon perceived need. The foundation of SSM is to develop a

system status management plan.

In 1986, Stout further detailed the use of CAD to enhance SSM.

<outbind://38/#_edn3> [3] He stated, " My own opinion is that it becomes

impossible to reliably handle SSM controls on a manual basis when your peak

load coverage exceeds seven or eight units. After that level, you need

automation. "

The advantages of SSM, as detailed by Stout, are:

* Reduce non-emergency service delays

* Equalize service among neighborhoods

* Safely " make room " for non-emergency service production at low

marginal cost

* Reduce the use of on-call crews

* Reduce the frequency of post-to-post moves

* Equalize workloads among crews

* Differentiate workloads of 24-hour crews from those of short shift

crews.

* Furnish better mutual aid service

* Reduce use of mutual aid service

* Cut overtime

* Employee schedules more convenient to crews

* Battle " cream-skimmers " working your market.

* Cut production costs without hurting response time performance.

In 1989, in response to criticism of SSM, Stout published another article in

JEMS that supposedly debunked the 6 " so-called " myths of SSM.

<outbind://38/#_edn4> [4]

Fallacies

With this introduction in mind, let's look at the fallacies of this plan.

1. No peer review publications. System status management was introduced

in several issues of the Journal of Emergency Medical Services (JEMS). JEMS

is a U.S. EMS trade magazine and not peer-reviewed. A literature search

failed to identify any scientific paper detailing the effectiveness of SSM.

Several papers are written in scientific journals-but each is written under

the premise that SSM is a proven system. <outbind://38/#_edn5> [5],

<outbind://38/#_edn6> [6] The burden of proof for a particular system or

practice is upon the proponents of such a system. With SSM, many in EMS

adopted it at face value because it " intuitively " made sense or they were

dazzled by suggested cost savings and improvements in efficiency.

2. Calls are predictable. It is intuitive that there will be more EMS

calls during times when there are more cars on the road. And, it is

intuitive that accidents are more likely to occur on roads. Thus, it makes

sense to have an adequate number of ambulances during drive time and to

position those ambulances where they can rapidly access major thoroughfares.

Now, this is where SSM falls apart. It is statistically impossible, with ANY

degree of accuracy, to predict where an ambulance call will occur (either

geographically or temporally) based upon 20 weeks of data. In discussing the

concept of SSM with 2 statisticians who hold doctorates, I asked how many

weeks of data would be necessary to make an EMS call (or trend) prediction

with any degree of scientific accuracy for a city the size of Fort Worth

Texas (approximately 800,000 people). One said 20 years and the other said

100 years. Both pointed to the inability of weather service to accurately

predict the high temperature for a day. With over 100 years of data,

meteorologists can predict, with limited scientific accuracy, what the high

temperature for a given day will be. Despite this, they are often wrong.

And, they are dealing with a single variable!

The ability to predict where and when a call will occur is

nothing more than the statistical term probability. By definition,

probability is a numerical quantity that expresses the likelihood of an

event and is written as:

Pr {E}

The probability Pr {E} is always a number between 0 and 1. For example, each

time you toss a coin in the air it will fall heads or tails. If the coin is

not bent, it will equally fall heads and tails:

However, with SSM we are using multiple random variables. The mean of a

discrete random variable (Y) is defined as:

where all the y1's are the values that the variable takes on and the

sum is taken over all possible values. The mean of a random variable is

also known as the expected value and is often written as E(Y) (thus E(Y)

= .)

Consider trying to predict where a call will occur in Fort

Worth, Texas. Say, for example, there are 200,000 addresses in the CAD.

There are 1,440 minutes in a day. Thus, what are the chances of making a

calculation with this many variables that is nothing more than chance? The

answer? Virtually impossible-even with a super computer. Furthermore, if an

EMS system ever gathered enough historic and geographic data to make a

prediction as to call time a location, the socioeconomic status of the city

will have changed making the predictions irrelevant.

3. Reduce non-emergency service delays. In theory, SSM is designed to

reduce non-emergent delays. However, in most systems that use SSM,

non-emergency delays remain a major problem. The categorization of calls

(and the low priority of non-emergency calls) continues to bump

non-emergency calls down while ambulances are posted to perceived need areas

in the event an emergency call comes in.

4. Equalize service among neighborhoods. This is one of the biggest

fallacies of SSM. We know, from empiric studies, that ambulance demand is

higher in low socioeconomic areas and areas where large numbers of elderly

people live (also often low socioeconomic areas). Cadigan and Bugarin found

that differences in EMS demand are related to median income, percentage of

the population more than 65 years of age, and percentage of people living

below the poverty level. Increased EMS demand was found in areas where a

significant percentage of the population is greater than 65 years of age or

living below the poverty level. <outbind://38/#_edn7> [7] Thus, if SSM is

working as it should (diverting ambulances from predicted low call volume

areas to predicted high call volume areas), ambulances should be routinely

diverted from the younger and more affluent areas of town to regions where

the population is older and living below the poverty level. This, in fact,

discriminates against parts of town that use EMS infrequently (and parts of

town where the majority of taxes are paid).

5. Safely " make room " for non-emergency service production at low

marginal cost. In the U.S., reimbursement is better (and more reliable) for

non-emergency calls than emergency calls. However, in Canada, the

differences in reimbursement are much less. Thus, SSM will not significantly

benefit Canadian EMS systems from this perspective.

6. Reduce the use of on-call crews. Here, Stout is being honest. SSM is

designed to reduce staffing. More importantly, it is designed to reduce

costs as posting ambulances from a central facility decreases the need for

brick and mortar stations-a significant cost for EMS systems. This is

particularly true for " for-profit " EMS systems in the U.S. that must also

pay property taxes (ad-valorem) on brick and mortar stations (governmental

agencies do not have to pay taxes). Looking beyond the smoke and mirrors,

one of the main purposes of SSM is to get as much work as possible out of a

subset of employees before bringing in back-up personnel which may cost

overtime.

7. Reduce the frequency of post-to-post moves. Another fallacy! It is

not uncommon for an EMS unit to travel 100-200 miles in a day and only run 3

calls-the remainder of the time moving from post-to-post. Remember, the CAD

cares not about the crew-only the location of the ambulance.

8. Equalize workloads among crews. If the system is not busy, SSM can

equalize the workload. However, if the system is busy, EMS units that are

busy stay busy. In many cities, hospitals are located downtown or in lower

socioeconomic areas. Thus, every time a crew takes a patient to the

hospital, they are closer to the next call when they clear the hospital.

This is why some crews will run emergency calls all day while another crew

does nothing but posts.

9. Differentiate workloads of 24-hour crews from those of short shift

crews. This sounds good on paper. But, the CAD does not know a 24-hour crew

from another crew. It simply selects the next closest ambulance regardless.

10. Furnish better mutual aid service. In the PUM, EMS systems are often

financially penalized when they provide mutual aid-especially if it delays

response times in their primary response area. Thus, systems using SSM are

often reluctant to enter into mutual aid agreements with surrounding

agencies. When this does occur, mutual aid is provided to the system using

SSM more than system ambulances responding to neighboring communities (which

are often suburbs).

11. Reduce use of mutual aid service. This is a non-sequitur. Stout

wants to furnish better mutual aid service and, at the same time, reduce the

use of mutual aid. The latter is the real preference as using mutual aid may

be accompanied by a financial penalty. Thus, in many SSM systems, when the

system reaches capacity-ambulances are asked to use lights and sirens to

decrease transport times instead of asking for help from neighboring

agencies.

12. Cut overtime. This is absolutely a goal. Cutting overtime cuts

expenses. However, it fails to take into consideration other factors. Using

a weekly cycle, the EMS system using SSM may drop the number of ambulances

on a Saturday. But, if the weather on that day happens to turn bad, or a

localized disaster occurs, personnel must be called in.

13. Employee schedules more convenient to crews. I dare you to find an

SSM system where people like the schedules. Sometimes the schedules are

contrary to the normal circadian rhythm and, other times, the schedule is so

awkward that people have trouble adapting. For example, going in at 7:00 PM

and working until 3:00 AM is more stressful than typical 12-hour or 8-hour

shifts.

14. Battle " cream-skimmers " working your market. This is more a U.S.

phenomenon, But, as stated above, part of the goal of SSM is to keep " for

profit " ambulances out of the non-emergency transfer market. In fact, most

PUMs have exclusivity agreements where they are the only service used to

transport any patient within the city. This leads to the problems with

non-emergency patients already described.

15. Cut production costs without hurting response time performance.

There is some truth here. Production costs are cut at the expense of

personnel! Ambulances and personnel are relatively inexpensive (compared to

brick and mortar stations). Thus, push personnel and the ambulances to their

maximum-after all, they are expendable. It is no wonder that the incidence

of back pain in Ottawa increased by 71% following the implementation of SSM.

<outbind://38/#_edn8> [8] Furthermore, EMS personnel in Ottawa spent 51% of

their time roaming.

Summary

Thus, to my colleagues in Canada, do not make the same mistake we have in

the States. SSM is a bad idea and totally based on pseudoscience. It is

promoted by consultants and experts who have never taken a look at the

science (or lack thereof) behind the practice. Canada has a good EMS system

and low employee turnover. SSM will drive away personnel in Canada as it has

in the U.S. Consider this, why has not a single major fire department in the

US (including those who operate the ambulance service) adopted SSM? The

reason is obvious. They looked and did not find the system sound. Don't be

dazzled by statistics and buzz words. The consultants will tell you that

once SSM was instituted in Tulsa, Oklahoma, the response time decreased from

6 minutes 46 seconds to 6 minutes 9 seconds (statitistically significant-but

not clinically significant). At the same time, maintenance costs increased

by 38% and miles travelled increased by 19%. <outbind://38/#_edn9> [9] They

always seem to leave that last part out. <outbind://38/#_edn10> [10]

References

_____

<outbind://38/#_ednref1> [1] Stout JL. System Status Management: The

Strategy of Ambulance Placement. Journal of Emergency Medical Services

(JEMS. 1983;9(5):22-32,

<outbind://38/#_ednref2> [2] Stout J. The public utility model, Part I:

Measuring your system. Journal of Emergency Medical Services (JEMS).

1980;6(3):22-25.

<outbind://38/#_ednref3> [3] Stout JL. Computer-Aided What? Journal of

Emergency Medical Services (JEMS). 1986;12(12):89-94.

<outbind://38/#_ednref4> [4] Stout JL. System Status Management: The Fact

Is, It's Everywhere. Journal of Emergency Medical Services (JEMS).

1989;14(4):65-71

<outbind://38/#_ednref5> [5] Stout JL, Pepe PE, Mosseso VN Jr. All advanced

life support versus tiered response ambulances. Prehospital Emergency

Care.2000:4(1):1-6

<outbind://38/#_ednref6> [6] Hauswald M, Drake C. Innovations in emergency

medical services. Emergency Medicine Clinics of North America.

1990;8(1):135-144

<outbind://38/#_ednref7> [7] Cadigan RT, Bugarin CE. Predicting demand for

emergency ambulance service. ls of Emergency Medicine. 1989;18:618-621.

<outbind://38/#_ednref8> [8] Morneau PM, Stothart JP. My aching back: Th

effects of system status management and ambulance design on EMS personnel.

Journal of Emergency Medical Services (JEMS);1999:24(8):36-40

<outbind://38/#_ednref9> [9] Hough TH. A View from the Street: System

Status Management. Journal of Emergency Medical Services (JEMS).

1986;12(12):48-50

<outbind://38/#_ednref10> [10] Bledsoe BE. EMS Myth # 7: System Status

Management lowers response time and enhances patient care. Emergency Medical

Services. 2003;32(9):158-159

September 26, 2005