EDITOI ALS The Need for ALS in Urban and Suburban EMS Systems Emergency m e d i c a l services (EMS) s y s t e m configuration varies w i d e l y in the 200 m o s t p o p u l o u s U n i t e d States cities. 1 Some cities provide only basic life support (BLS) emergency care to their citizens. Others staff all vehicles w i t h at least one advanced life support (ALS) provider (allALS system). M a n y systems use a c o m b i n a t i o n of BLS and ALS units in a variety of tiered configurations (mixed BLS/ ALS system).1, 2 N o n t r a n s p o r t i n g f i r s t - r e s p o n d e r u n i t s w i t h or w i t h o u t d e f i b r i l l a t i o n c a p a b i l i t y are b e c o m i n g more frequent in all s y s t e m configurations. 1-3 W h a t s h o u l d be the m i n i m u m acceptable level of care on every transporting a m b u l a n c e in a urban and suburban (nonrural) EMS system? A recent survey of the s y s t e m s that are in place today reveals that all b u t three of the 200 m o s t p o p u l o u s cities include some degree of ALS ambulance coverage.1 Is it medically, economically, or m o r a l l y defendable to accept less t h a n all-ALS coverage (at least one ALS provider on each transporting a m b u l a n c e unit)? We believe not. Eisenberg h a s r e c e n t l y s h o w n t h a t there is a "doseeffect" r e l a t i o n s h i p b e t w e e n EMS s y s t e m c o n f i g u r a t i o n and o u t c o m e from out-of-hospital cardiac arrest, a This is one appropriate end p o i n t w i t h w h i c h to judge an EMS s y s t e m ' s effectiveness b e c a u s e cardiac arrest t e s t s e v e r y c o m p o n e n t i n t h e s y s t e m . 4 T h e p r o b l e m o c c u r s frequently; it has an easily m e a s u r e d o u t c o m e (life or death); and effective t r e a t m e n t is available, practical, and t i m e dependent. Bl2S-only s y s t e m s result in a p p r o x i m a t e l y a 5% survival from out-of-hospital cardiac arrest. 3 Mixed BLS/ALS syst e m s that provide either BLS or ALS t r e a t m e n t and transport based on p r e s u m p t i v e p a t i e n t needs are rapidly disappearing (82% of the top 200 cities respond w i t h ALS to all emergencies, up from 63% the previous year)J Having the 911 c e n t e r o p e r a t o r a t t e m p t to triage a BLS or ALS responder u n i t to a call based on the caller's description or having BLS u n i t s transport selected patients to the hospital is a p o t e n t i a l "failure p o i n t " in any EMS system. This is analogous to a two-tiered police s y s t e m in w h i c h the 911 c e n t e r o p e r a t o r tries to decide w h i c h type of u n i t (armed or unarmed) to send to each e m e r g e n c y call. It is just a m a t t e r of t i m e until s o m e o n e m a k e s a wrong triage decision. In Kansas City, Missouri (an all-ALS s y s t e m by the above definition), 11% of r o u t i n e n o n e m e r g e n c y transports that were thought to require BLS~only care at the t i m e of d i s p a t c h a c t u a l l y r e c e i v e d an ALS s k i l l or procedure during the run. 5 Braun and colleagues have recently suggested that the o p t i m a l l y efficient EMS s y s t e m should provide a m i x e d BLS/ALS response. 2 We believe that their conclusion is incorrect because it fails to take into account the n o m i n a l cost differential b e t w e e n m i x e d BLS/ALS and all-ALS systems. W h e n t h e costs of e m e r g e n c y and n o n e m e r g e n c y services are compared, the cost of upgrading from a m i x e d 19:12 December 1990
BLS/ALS response to an all-ALS s y s t e m is m i n i m a l w h e n spread among thousands of calls. For example, in Richmond, Virginia, a city t h a t has c o m b i n e d its emergency and n o n e m e r g e n c y c o m p o n e n t s into one system, the difference a m o u n t s to less t h a n $2.88 per a m b u l a n c e r u n over all s y s t e m r e s p o n s e s (Figure). T h i s is a c t u a l l y an o v e r e s t i m a t e of the true cost per run because an all-ALS s y s t e m can always send the nearest vehicle (whether assigned to emergency or n o n e m e r g e n c y duty) to an emergency call, resulting in a need for fewer a m b u l a n c e s to adequately cover a service territory as compared w i t h a m i x e d BLS/ALS system. Such a configuration never allows a ;'failure p o i n t " to occur in the 911 center because there is no triage of calls to a BLS or ALS response. Such errors n o t only jeopardize p a t i e n t care, but m a y require dispatch of a second u n i t (the ALS response) to w o r k a life-threatening call, tying up two u n i t s instead of one. Thus, there is no substantive e c o n o m i c justification for not upgrading to an all-ALS system. A m i x e d BLS/ALS response also exposes the s y s t e m to a d d i t i o n a l risk of litigation. In a recent study, the m o s t frequent causes of litigation in an urban EMS s y s t e m rel a t e d to acts of o m i s s i o n , i n c l u d i n g n o t p r o v i d i n g ALS care or not arriving in a t i m e l y manner. 6 A n all-ALS syst e m reduces this risk by guaranteeing that the patient will be assessed and treated by an individual w h o has the highest level of skill in the profession. Examples of cities w i t h all-ALS s y s t e m s i n c l u d e P i n e l l a s C o u n t y , Florida; Ft Wayne, Indiana; Kansas City, M i s s o u r i ; Reno, N e v a d a ; Tulsa, O k l a h o m a ; Fort Worth, Texas; and Richmond, Virginia. The cardiac arrest p a t i e n t is n o t the only beneficiary of an all-ALS system. In a d d i t i o n to airway m a n a g e m e n t , IV line, and a s s e s s m e n t skills, ALS providers can a d m i n i s t e r medication. T h e recent discovery that long-term disability from spinal cord t r a u m a can be lessened in some patients by the early a d m i n i s t r a t i o n of m e t h y l p r e d n i s o l o n e 7 suggests that field ALS skills could become even m o r e important in selected injuries. Adding a first responding, defibrillating tier to an efficient ALS s y s t e m can yield 25% or more out-of-hospital cardiac arrest survival in m a t u r e EMS systems. 3,s,9 From a m e d i c a l standpoint, this is the m o s t effective EMS configuration known. But is it cost effective to add a firstresponding, defibrillating tier followed by an all-ALS response? We believe it is. BLS a m b u l a n c e s or first r e s p o n d i n g u n i t s can be upgraded to a u t o m a t e d defibrillation capability w i t h minim a l expense and t r a i n i n g J ° A u t o m a t e d defibrillators cost a p p r o x i m a t e l y $3,000 to $8,000 and require only two to four hours of a d d i t i o n a l t r a i n i n g for first responders or e m e r g e n c y m e d i c a l t e c h n i c i a n s . T h i s is a n o m i n a l expense c o m p a r e d w i t h t h e cost of a t y p i c a l a m b u l a n c e ( $ 5 0 , 0 0 0 to $100,000) or a f i r e t r u c k ( $ 2 5 0 , 0 0 0 to
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EDITORIALS
F I G U R E . Example of the incremental cost comparison of
Personnel Cost $3,000 per year differential between ALS and BLS provider Each person works 2,496 hours/year (48 hours per week) A 24-hour unit, 365 days = 8,736 hours per year No. of ALS full-time equivalents (FTEs) per unit = 8,736/2,496 = 3.5 FTEs Seven units x 3.5 = ALS FTEs = 24.5 total ALS FTEs Total personnel cost differential = 24.5 x $3,000 = $73,500 per year Nonpersonnel Cost ALS equipment/supplies, approximately $15,000 per unit Average life expectancy of equipment - seven years Ten full sets of ALS equipment required for seven units (reserve + on line) $15,000 x 10 = $150,000 Average life expectancy of equipment of seven years = $21,428 annual cost Total Incremental Cost Personnel $73,500 Nonpersonnel $21,428 $94,928 Per-Transport Cost $94,928 per year / 33,000 transports = $2.88 per transport
$500,000). W e b e l i e v e t h a t ALS w i t h a f i r s t - r e s p o n d i n g t i e r c a p a b l e of r a p i d d e f i b r i l l a t i o n is t h e m i n i m u m a c c e p t a b l e l e v e l of care i n a n u r b a n or s u b u r b a n E M S s y s t e m . J u s t as p o l i c e a n d fire p r o t e c t i o n is m a n d a t e d b y law, w e b e l i e v e t h e p u b l i c h a s a r i g h t to p r o m p t , t r a i n e d , e q u i p p e d ALS care a n d t h a t s u c h a l e v e l of e m e r g e n c y r e s p o n s e c a n b e prov i d e d b y u p g r a d i n g a n e x i s t i n g BLS or m i x e d BLS/ALS system at a modest incremental expense. The only exception would be in rural areas where the population density and v o l u m e of E M S c a l l s c o u l d n o t j u s t i f y t h e e x p e n s e of m a i n t a i n i n g a n all-ALS s y s t e m . It is t i m e for e m e r g e n c y
an alJ-ALS system versus a m i x e d BLS/ALS. Data from Richmond, Virginia, comparing the per-transport cost of having 14 units at the ALS level versus seven ALS and seven BLS.
p h y s i c i a n s i n all u r b a n a n d s u b u r b a n p r a c t i c e e n v i r o n m e n t s s e r v e d b y less o p t i m a l l y c o n f i g u r e d E M S s y s t e m s to p r e s e n t t h e s e a r g u m e n t s to t h e i r l o c a l g o v e r n m e n t offic i a l s to d e m a n d a s y s t e m u p g r a d e as s o o n as p o s s i b l e .
Joseph P Ornato, MD Edward M Racht, MD Joseph J Fitch, PhD John F Berry, MPA Internal Medicine Section of Emergency Medical Services Medical College of Virginia Richmond 1. Keller RA, Forinash M: EMS in the United States: A survey of providers in the 200 most populous cities. ] Emerg Med Serv 1990;15:79-100. 2. Braun O, McCallion R, Fazackerley J: Characteristics of midsized urban EMS systems. Ann Emerg Med 1990;19:536-546. 3. Eisenberg MS, Horwood BT, Cummins RO, et al: Cardiac arrest and resuscitation: A tale of 29 cities. Ann Emerg Med 1990;19:179-186. 4. Eisenberg MS: Quality assurance: Is it possible? EMS Forum, ACEP Scientific Assembly, San Francisco, November 1987. 5. Overton J: The use of advanced procedures on presumptively defined basic life support ambulance responses. Presentation to Board of Trustees, Metropolitan Ambulance Services Trust, Kansas City, Missouri, November 1989. 6. Goldberg RJ, Zautcke JL, Koenigsberg MD, et al: A review of prehospital care litigation in a large metropolitan EMS system. Ann Ernerg Med 1990;19:557-561. 7. Bracken MB, Shepard MJ, Collins WF, et al: A randomized, controlled trial of methylprednisolone or naloxone in the treatment of acute spinalcord injury. Results of the second national acute spinal cord injury study. N EngI J Med 1990;322:1405-1411. 8. Eisenberg MS, Hallstrom AP, Copass MK, et al: Treatment of ventricular fibrillation with emergency medical technician defibrillation. JAMA 1984;251:1723-1726. 9. Weaver WE), Cobb LA, Fahrenbruch CE, et al: Use of the automatic external defibrillator in the management of out-of-hospital cardiac arrest. N Engl ] Med 1988;319:661-666. 10. Ornato Jp, Craren EJ, Gonzalez ER, et al: Cost-effectiveness of defibrillation by emergency medical technicians. Am J Emerg Med 1988; 6:108-112.
What is 'Major Trauma?' In t h e i r c o n t r i b u t i o n t o t h i s i s s u e of Annals, B a x t a n d U p e n i e k s call o u r a t t e n t i o n to t h e c h a r a c t e r i z a t i o n of injury. T h e y p r o p o s e a d e f i n i t i o n of m a j o r t r a u m a b a s e d o n the services provided, findings at operation, and outcome (death) for i n j u r e d p a t i e n t s . O t h e r s h a v e p r o p o s e d defini-
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t i o n s of m a j o r t r a u m a b a s e d o n t h e l i k e l i h o o d of d e a t h a s s o c i a t e d w i t h i n j u r i e s of g i v e n s e v e r i t y . 1 D o e s e i t h e r approach "fully" define major trauma? T h e I n j u r y S e v e r i t y S c o r e (ISS) 2 w a s d e v e l o p e d to e v a l u ate motor vehicle accident victims who sustained multi-
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BLS/ALS response to an all-ALS s y s t e m is m i n i m a l w h e n spread among thousands of calls. For example, in Richmond, Virginia, a city t h a t has c o m b i n e d its emergency and n o n e m e r g e n c y c o m p o n e n t s into one system, the difference a m o u n t s to less t h a n $2.88 per a m b u l a n c e r u n over all s y s t e m r e s p o n s e s (Figure). T h i s is a c t u a l l y an o v e r e s t i m a t e of the true cost per run because an all-ALS s y s t e m can always send the nearest vehicle (whether assigned to emergency or n o n e m e r g e n c y duty) to an emergency call, resulting in a need for fewer a m b u l a n c e s to adequately cover a service territory as compared w i t h a m i x e d BLS/ALS system. Such a configuration never allows a ;'failure p o i n t " to occur in the 911 center because there is no triage of calls to a BLS or ALS response. Such errors n o t only jeopardize p a t i e n t care, but m a y require dispatch of a second u n i t (the ALS response) to w o r k a life-threatening call, tying up two u n i t s instead of one. Thus, there is no substantive e c o n o m i c justification for not upgrading to an all-ALS system. A m i x e d BLS/ALS response also exposes the s y s t e m to a d d i t i o n a l risk of litigation. In a recent study, the m o s t frequent causes of litigation in an urban EMS s y s t e m rel a t e d to acts of o m i s s i o n , i n c l u d i n g n o t p r o v i d i n g ALS care or not arriving in a t i m e l y manner. 6 A n all-ALS syst e m reduces this risk by guaranteeing that the patient will be assessed and treated by an individual w h o has the highest level of skill in the profession. Examples of cities w i t h all-ALS s y s t e m s i n c l u d e P i n e l l a s C o u n t y , Florida; Ft Wayne, Indiana; Kansas City, M i s s o u r i ; Reno, N e v a d a ; Tulsa, O k l a h o m a ; Fort Worth, Texas; and Richmond, Virginia. The cardiac arrest p a t i e n t is n o t the only beneficiary of an all-ALS system. In a d d i t i o n to airway m a n a g e m e n t , IV line, and a s s e s s m e n t skills, ALS providers can a d m i n i s t e r medication. T h e recent discovery that long-term disability from spinal cord t r a u m a can be lessened in some patients by the early a d m i n i s t r a t i o n of m e t h y l p r e d n i s o l o n e 7 suggests that field ALS skills could become even m o r e important in selected injuries. Adding a first responding, defibrillating tier to an efficient ALS s y s t e m can yield 25% or more out-of-hospital cardiac arrest survival in m a t u r e EMS systems. 3,s,9 From a m e d i c a l standpoint, this is the m o s t effective EMS configuration known. But is it cost effective to add a firstresponding, defibrillating tier followed by an all-ALS response? We believe it is. BLS a m b u l a n c e s or first r e s p o n d i n g u n i t s can be upgraded to a u t o m a t e d defibrillation capability w i t h minim a l expense and t r a i n i n g J ° A u t o m a t e d defibrillators cost a p p r o x i m a t e l y $3,000 to $8,000 and require only two to four hours of a d d i t i o n a l t r a i n i n g for first responders or e m e r g e n c y m e d i c a l t e c h n i c i a n s . T h i s is a n o m i n a l expense c o m p a r e d w i t h t h e cost of a t y p i c a l a m b u l a n c e ( $ 5 0 , 0 0 0 to $100,000) or a f i r e t r u c k ( $ 2 5 0 , 0 0 0 to
Annals of Emergency Medicine
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EDITORIALS
F I G U R E . Example of the incremental cost comparison of
Personnel Cost $3,000 per year differential between ALS and BLS provider Each person works 2,496 hours/year (48 hours per week) A 24-hour unit, 365 days = 8,736 hours per year No. of ALS full-time equivalents (FTEs) per unit = 8,736/2,496 = 3.5 FTEs Seven units x 3.5 = ALS FTEs = 24.5 total ALS FTEs Total personnel cost differential = 24.5 x $3,000 = $73,500 per year Nonpersonnel Cost ALS equipment/supplies, approximately $15,000 per unit Average life expectancy of equipment - seven years Ten full sets of ALS equipment required for seven units (reserve + on line) $15,000 x 10 = $150,000 Average life expectancy of equipment of seven years = $21,428 annual cost Total Incremental Cost Personnel $73,500 Nonpersonnel $21,428 $94,928 Per-Transport Cost $94,928 per year / 33,000 transports = $2.88 per transport
$500,000). W e b e l i e v e t h a t ALS w i t h a f i r s t - r e s p o n d i n g t i e r c a p a b l e of r a p i d d e f i b r i l l a t i o n is t h e m i n i m u m a c c e p t a b l e l e v e l of care i n a n u r b a n or s u b u r b a n E M S s y s t e m . J u s t as p o l i c e a n d fire p r o t e c t i o n is m a n d a t e d b y law, w e b e l i e v e t h e p u b l i c h a s a r i g h t to p r o m p t , t r a i n e d , e q u i p p e d ALS care a n d t h a t s u c h a l e v e l of e m e r g e n c y r e s p o n s e c a n b e prov i d e d b y u p g r a d i n g a n e x i s t i n g BLS or m i x e d BLS/ALS system at a modest incremental expense. The only exception would be in rural areas where the population density and v o l u m e of E M S c a l l s c o u l d n o t j u s t i f y t h e e x p e n s e of m a i n t a i n i n g a n all-ALS s y s t e m . It is t i m e for e m e r g e n c y
an alJ-ALS system versus a m i x e d BLS/ALS. Data from Richmond, Virginia, comparing the per-transport cost of having 14 units at the ALS level versus seven ALS and seven BLS.
p h y s i c i a n s i n all u r b a n a n d s u b u r b a n p r a c t i c e e n v i r o n m e n t s s e r v e d b y less o p t i m a l l y c o n f i g u r e d E M S s y s t e m s to p r e s e n t t h e s e a r g u m e n t s to t h e i r l o c a l g o v e r n m e n t offic i a l s to d e m a n d a s y s t e m u p g r a d e as s o o n as p o s s i b l e .
Joseph P Ornato, MD Edward M Racht, MD Joseph J Fitch, PhD John F Berry, MPA Internal Medicine Section of Emergency Medical Services Medical College of Virginia Richmond 1. Keller RA, Forinash M: EMS in the United States: A survey of providers in the 200 most populous cities. ] Emerg Med Serv 1990;15:79-100. 2. Braun O, McCallion R, Fazackerley J: Characteristics of midsized urban EMS systems. Ann Emerg Med 1990;19:536-546. 3. Eisenberg MS, Horwood BT, Cummins RO, et al: Cardiac arrest and resuscitation: A tale of 29 cities. Ann Emerg Med 1990;19:179-186. 4. Eisenberg MS: Quality assurance: Is it possible? EMS Forum, ACEP Scientific Assembly, San Francisco, November 1987. 5. Overton J: The use of advanced procedures on presumptively defined basic life support ambulance responses. Presentation to Board of Trustees, Metropolitan Ambulance Services Trust, Kansas City, Missouri, November 1989. 6. Goldberg RJ, Zautcke JL, Koenigsberg MD, et al: A review of prehospital care litigation in a large metropolitan EMS system. Ann Ernerg Med 1990;19:557-561. 7. Bracken MB, Shepard MJ, Collins WF, et al: A randomized, controlled trial of methylprednisolone or naloxone in the treatment of acute spinalcord injury. Results of the second national acute spinal cord injury study. N EngI J Med 1990;322:1405-1411. 8. Eisenberg MS, Hallstrom AP, Copass MK, et al: Treatment of ventricular fibrillation with emergency medical technician defibrillation. JAMA 1984;251:1723-1726. 9. Weaver WE), Cobb LA, Fahrenbruch CE, et al: Use of the automatic external defibrillator in the management of out-of-hospital cardiac arrest. N Engl ] Med 1988;319:661-666. 10. Ornato Jp, Craren EJ, Gonzalez ER, et al: Cost-effectiveness of defibrillation by emergency medical technicians. Am J Emerg Med 1988; 6:108-112.
What is 'Major Trauma?' In t h e i r c o n t r i b u t i o n t o t h i s i s s u e of Annals, B a x t a n d U p e n i e k s call o u r a t t e n t i o n to t h e c h a r a c t e r i z a t i o n of injury. T h e y p r o p o s e a d e f i n i t i o n of m a j o r t r a u m a b a s e d o n the services provided, findings at operation, and outcome (death) for i n j u r e d p a t i e n t s . O t h e r s h a v e p r o p o s e d defini-
152/1470
t i o n s of m a j o r t r a u m a b a s e d o n t h e l i k e l i h o o d of d e a t h a s s o c i a t e d w i t h i n j u r i e s of g i v e n s e v e r i t y . 1 D o e s e i t h e r approach "fully" define major trauma? T h e I n j u r y S e v e r i t y S c o r e (ISS) 2 w a s d e v e l o p e d to e v a l u ate motor vehicle accident victims who sustained multi-
Annals of Emergency Medicine
19:12 December 1990
