FW: Houston EMS Description

[Guest guest]

There has been a number of posting regarding HFD's deployment. Last

night, I forwarded a couple of messages to Dr. Persse. Dr.

Persse has provided the following description of the City's deployment,

credentialing, and oversight processes.

************************************************

, MPA

Chief Administrative Officer

Montgomery County Hospital District

________________________________

From: Persse, - HFD

Sent: Tuesday, February 28, 2006 12:54 PM

To: , ; Kirk Mahon

Cc: Almaguer, - HFD; Persse, - HFD

Subject: Houston EMS Description

-

Thank you for forwarding me the concerns about EMS in Houston.

For those who are unfamiliar with the HFD EMS system allow me to give a

brief description (it is long!):

EMS 2006 description - abbreviated

EMERGENCY MEDICAL SERVICES IN THE CITY OF HOUSTON

By ordinance, the City of Houston Emergency Medical Services (EMS)

Program is solely responsible for all emergency medical calls received

from within the city limits. The EMS program is integrated into and

administrated through the 3200-member Houston Fire Department (HFD).

Scheduled interfacility transfers are handled by private ambulance

services. Unscheduled emergent emergency department to emergency

department (ED to ED) transfers are frequently referred to HFD.

All EMS personnel are also firefighters experienced in emergency rescue,

extrication, and the suppression of hazardous materials and conditions.

All firefighters are specifically trained and annually re-trained in

basic first-responder (FR) activities. Since 1981, new cadets in the

fire department are also EMT-trained.

More recently the Houston Fire Department has embarked on a redesign of

the EMS resource deployment scheme. The department is transitioning

from a tiered program using First Responder engine companies, BLS

ambulances and ALS ambulances to a tiered dispatch driven First

Responder engine companies, all BLS ambulances and ALS First Responder

Squads. Currently the department has 122 EMT staffed First Responder

Engine Companies and Ladder Trucks, 54 EMT staffed BLS ambulances, 21

paramedic staffed ALS ambulances, and 19 paramedic staffed Squads. The

paramedic Squads are centrally located and along major thoroughfare

corridors following the city's highest call volume areas. The tiered

dispatch system sends BLS resources to approximately 40% of all initial

dispatches and paramedic resources to 60% of all dispatches. Data shows

the BLS first responder " cancels " the ALS resources in approximately 70%

of the paramedic dispatches, returning the paramedic units to service

making them available for the next potential call. Upon initiation of

this program paramedic response times decreased 2.7 minutes in the

neighborhoods with the Squads, and over 1 minute across the remainder of

the city. Reports of severe injury are responded to by the closest

ambulance (ALS or BLS), and a Squad if necessary. Protocol dictates

that critically injured patients are to be immobilized and transported

as quickly as possible. As a result some critically injured patients

arrive before being intubated or having IV access established, but this

is offset by the prehospital time being reduced by over 10 minutes.

Physicians representing the various emergency centers in the Houston

area form an Emergency Medical Services committee of the County

Medical Society and advise and assist the EMS System Physician Director

in medical quality control and policy development. A strong emphasis is

placed on full-time, close physician supervision, including daily

on-scene evaluation and participation by the Physician Director and his

staff. In addition, six Sector EMS Captains, two Senior Captains and a

District Chief head each of the four 24-hour shifts of EMS operations.

These EMS supervisors are paramedics as well as Fire Department

officers. The supervisors report through a dual chain of command to the

Assistant Fire Chief for EMS and the Physician Director. They provide

education, quality improvement and trouble-shooting supervision over the

five to six BLS and seven or so ALS units in each sector. These (HFD)

supervisors also must respond to all cardiac arrests and other major

incidents in their jurisdiction and they provide excellent on-scene

quality assurance in such circumstances. These paramedic supervisors

offer minute-to-minute system monitoring and are the key link to the

quality of patient care in this extremely large system. They are often

accompanied by EMS fellows, Senior Emergency Medicine Residents or

Surgical Residents.

On-line medical direction is provided by the EMS Physician Director and

Assistant Medical Directors from a single base station with multiple

telemetry voice/electrocardiograph transmission capabilities. The

county-wide availability and status of all area hospital emergency

centers are also continually monitored at this location and regularly

updated on a website. The paramedics at the base station continuously

monitor the website so that EMS transport units can be appropriately

re-routed as necessary.

All aspects of EMS operations are continually re-evaluated and

scrutinized as part and parcel of their usual function. For example,

dispatch functions are routinely reviewed, beginning with very detailed

statistical analyses of all dispatches including: 1) types of calls

received; 2) the various levels of response; and 3) the specific

location of all incidents. In turn, these data points are correlated

with various types of patient care information such as case severity,

hospital destination, and procedures performed. Access to EMS is

facilitated by an enhanced 9-1-1 system, which relays medical calls

(within 10-15 seconds) from a central " neutral " public safety answering

point. All components of system response time such as time for the

9-1-1 relay, dispatch processing time, notification and departure time,

and actual response time to the scene (as well as patient contact time),

are carefully reviewed and well-analyzed, particularly in all cases of

major trauma and cardiac arrest. In-hospital follow-up and discharge

(outcome) information are accomplished citywide by close cooperation

with the medical and administrative staff of community hospitals.

Recently return of spontaneous circulation (ROSC) for VF patients has

been around 65%, but has been as high as 72% with a survival to hospital

discharge rate of 20 - 25%. The quality improvement efforts have

rigorously evaluated its own efforts and have been demonstrated to make

a statistically significant improvement in outcomes (Prehosp Emerg Care

Jan-Mar 2002). Patient satisfaction measures bear out the positive

impact of this EMS system's multi-faceted pursuit of excellence (Acad

Emer Med, Jan 2004). Also undergoing continuous scrutiny is the impact

of the advanced life-support system. Patients who suffer cardiac

arrests are followed through their hospitalization and for up to one

year after discharge. The successful strategies are analyzed and

reviewed by international experts for publication (Resuscitation,

October 2003). Houston's success with caring for the most critically

ill patients has been showcased in a recent review article stressing the

delivery of critical care medicine in the out-of-hospital environment

(Prehosp Emerg Care, Jan-Mar 2002).

Inquiries and complaints are handled by joint reviews from both official

HFD investigators as well as the Physician Director's staff. In recent

years, this activity has amounted to approximately 10

complaints/inquiries per month of which only an average of two are

medically related. The medical care problems generally involve

constructive feedback from emergency department physicians or even the

EMS personnel themselves. On the average, 20% are ruled as being valid

problems. Overall, most complaints involve a perception of " rudeness "

and most are made by bystanders. Overall, the annual incidence is about

65 complaints/inquiries per 100,000 patient contacts (Acad Emerg Med

June 1995).

Paramedics are initially trained with 1200 hours of standard curriculum,

compatible with Department of Transportation (DOT) stipulations (the

State of Texas requires 650 hours). Paramedics then qualify for the

National Registry Paramedic exam. However, prior to coming to full

status as a paramedic, the new candidate undergoes another minimum

period of four months of in-field apprenticeship and evaluation under

veteran preceptors, EMS physicians and HFD supervisors.

________________________________

From: ,

Sent: Monday, February 27, 2006 10:28 PM

To: Kirk Mahon

Cc: david.almaguer@...; david.persse@...

Subject: FW: Hydrofluoric acid

Dr. Mahon,

I work closely with Dr. Persse and the HFD management team. I

would encourage you to contact or someone from HFD administration

(I would recommend Dr. Almaguer). The speculation regarding HFD

and its current deployment has been very misleading.

They do have a large emphasis on Paramedic Squads and BLS transport

units. They have found it to be a good local solution to the problems

they have faced. has presented data on their deployment strategy

to many industry groups.

I have included Dr. Persse on my reply.

************************************************

, MPA

Chief Administrative Officer

Montgomery County Hospital District

________________________________

From: [mailto: ] On

Behalf Of Kirk Mahon

Sent: Monday, February 27, 2006 7:49 PM

To:

Subject: Re: Hydrofluoric acid

Wes,

Thanks for the info. Are you saying that inside 610 all the boxes have

EMTs

only and thus nobody can get iv access unless an " ALS intercept " occurs.

I

am not sure I understand. Are there seperate boxes and what percentage?

When I was in Houston over a decade ago they had a tiered response and

would

send out paramedics or EMT units depending. If that is the current

system,

then somehow the unconscious/not breathing part did not get translated

into

a paramedic response (think it use to be a " Level D " ).

Kirk D. Mahon, MD, ABEM

6106 Keller Springs Rd

Dallas, TX 75248