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Slow EMS response to fatal heart attack call in Naples pronmt<; n()licv review POT J, : Na... PaQe 1 of 4
10 0.... ~rt~t~~ Ageodaltem#/O P Mee"ogDate'lP,fr,
'"1^'" Presented by b~CCC ia.. \....\\ \\e.,
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.COI
Slow EMS response to fatal heart attack call in
Naples prompts policy review POLL
By AARON HALE
Saturday, April 2, 2011
Editor's note: The original story incorrectly estimated that the city of Naples
pays $12.6 million in EMS fees to Collier County. City officials said the city pays
about $2.6 million annually. The story has been corrected below.
NAPLES _ In pre-hospital emergencies, professionals often say that "seconds count."
But seconds turned into minutes in a fatal March 19 medical call, when a Collier
County EMS ambulance crew arrived on scene nearly 15 minutes after the 911 call
was placed and 10 minutes after Naples firefighters arrived.
Collier County Emergency Medical Services officials deny the ambulance's response
time directly led to the patient's death.
Still, this case and other reports of delayed ambulance response times in the city of
Naples are leading to questions on how ambulances are dispatched and the
effectiveness of communication between the multiple agencies charged with
responding to medical emergencies.
Policies for emergency response are under review and might be changed.
"I worry that if these issues continue, a patient could directly and significantly suffer,"
wrote Dan Bowman, deputy chief of Collier EMS in a March 31 email to the head of
county EMS.
Jackie Dean of 13th Street North called 911 after her 82-year-old mother, Daisy May
Cannon, complained of weakness and began vomiting on March 19.
After Naples firefighters arrived first and took her mother's vital signs, Dean said she
had to wait too long for an ambulance to arrive for hospital transport.
The delayed response was due in part to the "alpha" or low-priority label given to the
call, according to official reports. Ambulances don't respond "hot" with lights and sirens
for alpha calls.
To further complicate matters, the EMS ambulance, which left from a station
neighboring the Naples fire truck, initially went to the wrong address, and ambulance
-:http://www.naplesnews.com/news/20 11 /apr/02/collier-ems-response-times-naples-woman-d... 4/612011
Slow EMS response to fatal heart attack call in Naples prompts policy review POLL: Na...
, .' ' 10D,e~
personnel were unable to reach Naples firefighters by radio to clarify directions,
according to an EMS report.
Page 2 of 4
'j
Thirteenth Street North is split. One portion is west of Goodlette-Frank Road, but that
segment doesn't intersect with Goodlette-Frank Road. The other portion is east of
Goodlette-Frank. According to the EMS report, one paramedic thought he knew where
the call was coming from and directed the driver to the wrong portion of 13th Street
North.
After the ambulance finally arrived, the patient was loaded onto a stretcher.
According to reports, Cannon went into cardiac arrest while being transporting to the
hospital. She later died.
Bowman said initial reports reveal the patient didn't display "serious medical problems"
until she was in the ambulance.
He also said pending a quality assurance investigation into the matter, there is no
evidence to suggest the delayed ambulance response time contributed to the patient's
death.
Dean, still angry Friday over the delayed response, said her mother actually may have
"died from fright."
She explained that her mother was scared of the medical personnel on scene and
panicked as she was strapped into the stretcher.
However, Bowman admitted the issues of the ambulance going to the wrong place and
the lack of communication between agencies are concerning.
The paramedic who directed the ambulance driver to the wrong location was
disciplined by the agency.
*****
Doug Finlay, a Naples councilman, said that by his count there are at least four
instances, including the March 19 call, of slow EMS arrivals in the city. He pointed to a
similar nonfatal case on March 28 at a Third Street South restaurant.
In that call, a patron was suffering from dizziness, was in and out of consciousness,
and vomiting, according to city emails.
Although Naples firefighters arrived five minutes after the initial 911 call, an apparent
miscommunication between dispatch and EMS led to an ambulance arriving 21
minutes after the call, Naples Fire Chief Steve Mcinerny said.
"This entire medical episode took place in front of a very busy lunch hour crowd,
employees and manager," Mcinerny wrote in an email to EMS Chief Jeff Page.
"It appears we have a real problem," Finlay said.
http://www.naplesnews.comlnews/20 11 /apr/02/collier-ems-response-times-naples-woman-d... 4/612011
Slow EMS response to fatal heart attack call in Naples prompts policy rerUPIj;~.. fage 3 of 4
Finlay's chief complaints are the prioritization of medical calls and the frequency of
ambulances "getting lost" on emergency calls.
Collier County emergency personnel operate on a two-tiered structure, which is
designed for firefighters or law enforcement to arrive first on scene to a medical
emergency, with EMS paramedics following behind in more severe cases.
As part of the tiered emergency response system, medical calls are prioritized by
urgency by dispatch officers at either the Collier County Sheriff's Office or Naples
Police Department.
Bowman explained that it would be inefficient and too expensive to have an ambulance
arrive to even the most minor medical calls.
For priority calls, Bowman explained, ambulances go "hof' - meaning drivers fire up
the lights and sirens and take the right of way at intersections. On alpha calls,
however, ambulances travel without emergency lights and are available to respond to
other medical emergencies. They may not even arrive on scene if first responders can
handle the call.
"This policy is widely utilized throughout the EMS industry in order to decrease the risk
to the responders and (the) public from ambulances that are unnecessarily spreading
through traffic and intersections," Bowman explained.
Prioritization also leaves ambulances available to respond to more severe calls
However, Mcinerny said, there is some failure of under-prioritizing calls.
"This call was a priority," Mcinerny said of the Cannon call. "This taxpayer, this
resident, deserved a better response."
Bowman defended the protocol and his EMS personnel. He pointed out that Naples
firefighters didn't directly communicate via radio to EMS staff in either case, making it
more difficult for them to know the severity of the case.
Bowman suggested that instead of changing the entire system, officials need to re-
examine how calls are deemed low priority. He said first responders also need to
communicate directly with ambulance units if a call is more severe than initially
diagnosed.
Mcinerny, who insisted there is a good relationship between EMS and the Naples fire
department, said there is room for both agencies to improve communication.
Bowman said that while EMS officials are reviewing the concerns in Naples, they may
decide to temporarily drop alpha call protocol and go "hot" to all medical calls.
Meanwhile, Finlay said he just wants to see an end to the string of delayed responses.
He estimated the city pays the county $2.6 million annually for ambulance service.
http://www.naplesnews.com/news/20 11 /apr/02/collier-ems-response-times-naples-woman-d... 4/6/2011
. Slow EMS response to fatal heart attack call in Naples prompts policy revlwOIj;~ lre 4 of 4
"I do think for all the money we send to (Collier) EMS, the Naples residents should get
more than what we seem to be getting in return," Finlay said.
He added that he is taking steps to explore the idea of implementing a city-run
ambulance service, but is still in the beginning stages of that exploration.
_ Connect with Aaron Hale at http://www.naplesnews.com/staff/aaron-hale
=r-""s;: @ 2011 Scripps Newspaper Group - Online
III
http://www.naplesnews.com/news/20 l1/apr/02/collier-ems-response-times-naples-woman-d... 4/6/2011
COUNTY EMERGENCY MEDICAL
SERVICES
CONTENTS
· COUNTY EMS SUMMARY FORM USING PEAK SEASON
POPULATION PROJECTIONS
TABLE
CHART
· MAP - 2010 EMS STATIONS INVENTORY
· TABLE - 2010 EMS STATIONS INVENTORY
· COLLI.EREMS COST PER OWNED AND SHARED STATION
· TABLE - COLLIER EMS EQUIPMENT REPLACEMENT COST
. EMS EXISTING ZONES 1\1.AP
· EMS RESPONSE TIMES BY ZONE FOR PERIOD 10/1/08-9/30/09
· ALS AGREEMENT MAPS WITH EMS ZONES
. CHART - EMS TRAVEL TIM.ES
· CHART - EMS CARDIAC RESUSCITATION RATES
· CHART - EMS PERCENTAGE OF CARDIAC ARREST POST
HOSPITAL SURVIVALS
· CHART - EMS PERCENTAGE OF' TRANSPORTED VS. NOT
TRANSPORTED CALLS
· CHART- EMS NUMBER OF O{JT 0." ZONE RESPONSES
Agenda Item #: /0 D Meeting Date. "-1/.;). &'/11
Presented by: bee.; ~ 0. :',0, )./ lie I
, 1_---"'"
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145
1 0 0-6\
2010 AUIR FACILITY SUMMARY FORM
Facilitv Tvpe: Emergency Medical Services (Category B)
Level of Service Stand . prox. 1 l.mitll 6,400 population or O.O~apita)*
The ALS response time go I is 8 mi tes travel time 90% l?lthe time urban and..!!..!!!jrutes travel
time 90% of the time rural.
Unit Cost: $3,203,593 per new unit and $1,816,093 per co-located unit **
Available Inventory 9/30/10
Required Inventory 9/30/14
Proposed AUIR FY 10/11-14/15
5- Year Surplus Of (Deficit)
Units
24.5
27.1
2
( 0.6)
Value/Cost
$35,475,529 ***
$42,602,370
$ 3,750,000 ****
$(
Using the Peak Season Population method, the following is set forth:
Expenditures
AIJIR FY 10/11-14/15 Deficit under current LOS n.......... .............. $ 3,750,000
2002, 2005, & 2010 Bond Debt Service Payments........................... $.. 3,066.300
Total Expenditures...... . . . . . . . . . . . . .. . .. . . .. . . . . . . . . . . .. . . . . . . . . . . . . . .. .. .. . .. .. .. $ 6,816,300
Revenues
Impact Fees anticipated.......... .................... .......................... ... $ 415,236
Interest. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. $ 8,100
Carryforward (unspent cash as of September 20,2010)..................... $ 954,000
General Fund (Loan) from County Wide Capital Projects................... $__.1,68.~,964
'rotal Revenues..................................................................... $ 3,066,300
Additional Revenues Required or I.-evel of Service Standard Reduction..
*****
*The LO,):)'was changed from 1/15,000 population to 1/16,400population along with
the ALS response time goal of8 minutes travel time counfJ"~llide to 8 minutes travel time
90% of the time urban and 12 minutes travel time 90% of the time rural to tak-unto ..hr
consideration the contribution of the AIS En ine These changes were f\. 'V
approve :)' t e1('C on 11/5/07 at the 2007 A UIR. 7hrough the third quarter (~r FY
08/09 response time data reflected that this goal was accomplished 87% of the time
urban and 88% of the time rural.
The on-scene time goal for med flight is 15 minutes 85% of the time. Through the ]rd
quarter FY 09/10 data indicates this oly'cctive lilaoS' achieved 87.5% (~llhe time and the
goal of ]()()% ofcompletedjlights withoUl a safety issue {mechanical or operational} was
met 100% of the time.
146
~
100~
A LOSS of, Q00029 units per capi!f!..J][ 1 unit/34.652 populaY.Qll is the Impact Fee Study
level olservice and the basis jar the collection of impact fees, which is based on only the
EA1S stations owned by the County,
** E.mergency ",viedical SeQic:g~~l)epartment Unit Values
(1,0) Unit = 24 hour advance l~fe support emergency ground transport unit with
station/building.
(.0.5) Unit = 12 hour advanced l~fe support emergem.}' ground transport unit wi'ing
existing apparatus, stafledwith overtime personnel.
Unit Cost will be ac{justeeJ, as appropriate, based upon Board adoption ([/' the E1if,,':,'
Impact Fee Study update in pro&Tfess,
*** Calculated based 7 Otl/ned stations, 4 co-located stations and on 13.5 units
equipment only (2 stations not yet constructed are included as equipment only).
**** Calculated based on construction costs on~v fbr stations at J;'anderbilt/Logan and
US' 41 and Old 41. Land and equipment have already been purchased
***** Sources (?( funding for revenue dejicit could include a loan .from the General
Fund. additional user fee categories, reduction of service level. or other sources not yet
ident[jied.
EMS currently as 35 ambulances avai ble u)r service. Two trucks scheduled for
rcpJ.aCemenCin -ere not wo more scheduled for replacement in 2010
were not funded. Two ambulances were replaced in 20 I 0 utilizing carry forward from
revenues exceeding budget in 2009. Another was replaced through a five year lease
purchase. This leaves a deficiency of seven ambulances for FY 11.
147
10 D-eR
2010 AUIR - Emergency Medical Services
EMS has traditionally defined level of service standard as 1 unit! 15,000 population countywide.
This LOSS has evolved from a seasonal population, to permanent and then back again to
seasonal. During the 2005 AUIR, the shift from permanent to weighted resulted in a deficit of
available EMS units. The Board directed EMS to add four units to alleviate the deficit. During
the lattcr part of FY06, those f(mr units were staffed and brought on line. However, the facilities
to house these units have not been constructed. Two propelties have been purchased and two
ot11ers have been identified for joint projects with no land cost.
During the 2007 AUIR presentation to the CCPC and Productivity Committee, there was
considerable cli<:{,ll"-51nn to include the ALS Engines in determining levcl of service for EMS. i<J
EMS noted that if the response time goals were changed from 8 minutes countyw'ide (which
could never realistically be achieved because of the cost to provide sufficient coverage in the
rural areas), to 8 minutes urban and 12 minutes rural, and counting ALS Engine response, the
Department was very elose to where it needed to be. Based on the 26.5 umts filen in service, the
LOSS was at 1 unit/16,240 population. The outcome of this joint meeting was a
recommendation that the Bce adopt the 8 minute urban! 12 minute rural response time standard,
in conjunction with a 1116.400 population level of service standard. The Board subsequently
adopted the 8/12 minute, 1/16,400 population LOSS at the November 2007 AUIR meeting.
During the FY09 Budget Hearing, the Bec approved the elimination of two EMS units, for a net
of24.5 units in service. The adopted LOSS of 1/16,400 is illustrated at 24.5 units available. As
indicated in the chart based on the current population projection, a slight deticit begins in FYIO
and increases over the next few years. The three year deficit f{Jf FY II through FY 13 may he
acceptable to weather the current economic crisis. As indicated on the Summary Form, a
proposed station at Vanderbilt/Logan and US 41 and Old 41 would be two of the stations
proposed through FY 14-15.
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Source: Impact Fee Study
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Agenda Item #: to \) Meeting Date : ~
Presented by: -ih LL ~
1 0 o~ t~
.
A. . . s a matter of polI'tical gospel--an d survival--fireflghters
are sacrosanct. No matter the depths of a municipality's
budget crisis, neither the firefighters' ranks. pay nor ben-
efits ate touchable. There are no reductions in force for firefighters.
And yet. in cities all across the country, that's exactly what has been
happenh1g. The men and women in red are becoming asvt1lnerable
to budget cuts.as other municipal employees.
The new landscape has c1etrrly been shaped by the brutal fiscal
conditions in localities. In an era of such severe economic tmcer-
tainty, high-level munidpal officials-elected and otherwise-have
not bee.n shy ahout portraying firefighters as a group that has vacu-
umed up more than its fair share of municipal resources-whether
it's for salaries, equipment and firehouses. or for some of the most
generous retirement packages offered by local governments today;
But other factors have contributed to the new view, and one is a
question of efficacy. There's a growing discussion about whether-in
By Jonathan Walters
a:
~
In small and
large cities
alike, firefighters
have gone from
heroes to
budget bait.
Janllary 2011 I GOVERNING 31
FIRE FIGHT
1 0 D~ C~
a world with fewer fires and more emergency medical-related
incidents llud automobile accidents-firefighters are deploying
resources to maximum effect
R. .ight now, the cost of paying a.fi t 'efighter is fO. rem ost.
on city officials' minds. Take San Jose, Calif Over
the past decade, the cost of firefighter wages and
benefits in the big California city has increased
100 percent, while city revenues have only risen by 20 percent,
according to Michelle McGurk, a spokeswoman for the mayor's
office. The average firefighter, she says, now costs the city more
than $180,000 per yea.t: Moreover, the highest-paid employees in
San Jose aren't high-l(;VC1 officials,-or even the city manager-but
upper-level members of the city fire service. Firefighters with 30
years of service can retire as early as age 50, with 90 percent of
their salary.
That was just the beginning of the tough line that the San Jose
mayor's office took when it handed outpink slips to 49 firefighters
summarily rejected the idea, argui.11g that the city wasn't in as bad
fiscal shape as it claimed and thatfirefigbters were being asked to
bear more than their fair share of cuts,
Painting firefighters as something of a pampered class-well
paid with retirement packages that would be the envy of anyone
in either the private or public sectors-would have been unheard
of just a few years ago. Today, it's a widespread practice. After
spending nearly a decade on a post-9/11 pedestul, the profession
recently has been on the receiving end of more stringent scrutiny.
Government officials and the public they represent appear to be
taking a much harder look at exactly what they al'e buying when
asked to spend bigger and bigger bucks on firefighters, firefighting
equipment and emergency response.
In cities where firefighter layoffs haven't occurred, it has fre-
quently been due to concessions wrung from unions-despite
unions' reputation as tough negotiators. But it's not that the
unions have caved in easily to city demands. In Jacksonville, Fla.,
for instance, the firefighters'union at first rejected a contract
calling for a t\vo-year, 2 percent pay cut, and that for the first
time ever l'equired Single firefighters
with no dependents to contribute to
their health insurance. In the face of
rejection, the city promptly followed
through on its tlIreat to layoff 15 fire-
fighters, a messy process that involved
bumping another two dozen active
firefighters to lower-level jobs.
The move was the culmination
of several years of tough budgets f'Or
Jacksonvi1le, says Misty Skipper, a
city spokeswoman, In a city looking at
escalating employee costs of 20 per-
cent in the next five years, it means
that every employee in government
must sacrifice. It's patt of a new real-
ity, "In the pa;,1:, our public safety sec-
tors-police and fire- have essentially
been held harmless;" Skipper says.
"This year we knew the gap couldn't
be addressed just through nonpublic
safety areas."
In the face of layoffs, the Jack-
sonville firefighters' union capitu-
1ated. Besides the 2 percent pay cut,
single firefighters without depen-
dents \viII now contribute 5 percent
to their health-care coverage. while the IS laid-off firefighters
were reinsta ted with the recent ratification of the firefighters'
contract, the dty will still eliminate 15 fire and rescue positions
through attrition.
"Obviously, a pay cut is never good, especially when you're
already on the low end of the pay scale;' says Randy Wyse, presi-
dent of the Jacksonville Association of Firefighters. (Starting pay
for fire and rescue pers01mel in Jacksonville is just more than
$34,000, with additional pay available for medical training, fire-
8
Si'
a
5
~
last fall, a decision that the city laid directly at the feet of the San
Jose firefighter'S union, Local 230.. "Let me be very clear," McGurk
says, "we didn't have to layoff firefighters. It was the decisiOll
of Local 230. They could have come through with concessions."
With an open contract-the firefighter union's collective bar-
gaining agreement expired in June 2()09-the city asked Local
230, along with all other city unions with open contracts, to gjve
back roughly 10 percent in wage and benefit concessions in a deal
that would have saved the 49 firefibrbter positions. But Local 230
32 GOVERNING I January 2011
FIRE FIGHT
10D~
One of the big questions right now is whether the
fire'service is actually learning anytbing amid the
constant threat of <''1.lts, especially about smarter
' . W>Y' to deploy"""""", in ,n "'" oforni_.
budgets and departments. While police departments, especially
in larger cities, have embraced a more sophisticated and data-
driven approach to the work they do-allowing them to maintain
relatively high performance levels-there's been less willingness
on the fire service's part to embrace data as a way to revamp how
fire suppression, EMS and other cans are handled.
For the most part, firefighting .is still based on geographically
distributed, fixed stations staffed by a set number of personnel
who stand by and wait to be dispatched when needed. For the fire
says Bruce Hoovel~ chief of t1le Fargo Fire Department in North
Dakota. Fargo's protocols used to mirror San Jose's exactly. But
now Fargo fire h'Ucks only roll if "there's bleeding, breathing com-
plications or trauma:' Hoover says. "We now only respond for
true medical emergencies, and that's CUrt.Ul 1 Ull ,"vuul b,,~l, b l
1,000 a Y;-ar, and has keot aonArAtus and manuower III place for
real ~erenCleS!' _
But as mgtough questions about manpower and deployment
is difficult for many municipal officials who don't feel confident
tangling with the community's best and bravest. A way to do that,
however, without going toe-to-toe with the fire service, Wiec-
zorek says, is simply to ask departments for solid, up-to-date data
on demand, along with what measurable results a city is getting
for its TIre service dollal's.
What most municipalities will find
when they start asking good questions
about budgets, deployment and ser-
vice demands is that there aren't many
answers to those questions. "We are rou-
tinely called into communities to look at
manpower and deployment," Wieczorek
says. "We find across the board in small
and large jurisdictions that data is either
nonexistent or totally wrong!'
What drives firefighting in the U.S.,
for the most part, is long-standing prac-
tice, not good, current information on
what's actually happening on the ground,
including number of calls, response
times, seriousness of the incident, geo-
graphical distribution and time of day,
all measured in relation to the geometry
of fire service manpower, equipment and
deployment.
For exan1ple, iri one jurisdiction that
asked the lCMA to come in and do a
thorough analysis of demand, resources
and deployment, the lCMA team looked
at the busiest five minutes the fire depart-
ment had in a year. What did the team find? Even at its busiest
moment of the year, the city still bad seven idle units standing by
ready to respond, with 28 available firefighters. Those are just the
sorts of analyses-in combination wit11 the current budget crisis-
that have emboldened policymakers and budget writers to start
asking tougher questions about what fire departments really need
and how they do business-and asking them to either hold the line
on budgets or cut back
Looldng at both budgets and at more creative and data-driven
waysto handle staffing and deployment are key. "Don't get caught
up in the hyste1'ia h'ap ofbeIieving that if you pursue things like
brownouts and budget cuts that children are going to die and
seniol' citizens will burn up," Wieczorek says. "That might hap-
pen, but only if we keep doing business in the same old ways:' G
8
sz
Cl
5i
~
service to COl1tinue to peiform in these leaner times, Wieczorek
says, it is now going to have to actively embrace change-and
that's not something that comes easily to the. fire service. "The
old saying in the fire service," Wieczorek says, "is '100 ~ars of
tradition unimpeded by progress.'''
One of the most signific3l1t and widely recognized changes
in the fire and rescue service is that on average, most calls to fire
epartments now are for medical emergencies and not fires-
running about 80 percent EMS to 20 percent fire in most juris-
dictions where the fire service handles both. At the same time,
most calls are either false alanns or not particularly serious. Yet
too few fire departments have adapted very well to these realities.
For example, San Jose still sends an attack pumper with a full
complement of four firefighters to all emergency medical calls,.
Tying up four firefighters an;1." ";g./.'M "~l.t ow'mlly winds
up being minor medical emergencies doesn't make any sense,
~
-
34 GOVERNING' January 2011
E-mail jwalters@governing.com