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Z -t o r- m > ;;U r- oo( ~ (' '" b y .r.., f1J r r ~ a ""i )>' G) m z C > ::r m :s:: z c: :s:: OJ m ;:u \) \ b 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., <1 .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_---"'" C 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. 148 a: g r,J) - (j) I- :::l 1"(\ Z < Jj :::l Ox r,J) o ~ ::!i N ti.. UJ lUU'-'CR~ ""Cl o c s: o '0 ti o () "0 Q) "0 C Q) 15 <ll(") - Q) co m . 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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