Welcome to the latest issue of EMS on the Hill, a newsletter representing the work of a broad group of EMS organizations dedicated to achieving positive change and recognition for emergency medical services at the state and federal levels. In July 2007, this group of organizations met to review the recommendations of the 2006 IOM Crossroads report and develop priorities and action items to help make these recommendations reality. This newsletter will provide updates on those action items, plus discuss other critical industry issues.

NEMSAC TURNS FOCUS TO EMS ISSUES

At first meeting, new national advisory body finds a lot to look at

WASHINGTON, D.C. -- The newly created National EMS Advisory Council hit the ground running at its inaugural meeting in April.

The expert panel, appointed by the Secretary of Transportation, will advise NHTSA's Office of EMS. During a brain¬storming session to get things started, the group came up with a number of topics that need to be addressed.

"We've developed a comprehensive list of issues and considerations faced by EMS throughout the country," says Idaho EMS chief Dia Gainor, the council's chair.

Some of these issues include recruitment and retention of EMS personnel, quality assur¬ance, preparedness for multi¬casualty events, wait times at hospitals and the need for more federal grant money.

After the entire board has a chance to review the items, they will be prioritized. After that, committees will be established to address specific issues and develop action plans.

Drew Dawson, NHTSA's EMS director, told the group that the concept for a volunteer advisory panel had been "on and off the burner for a number of years." He said they have the ability to direct the future of EMS, and that he's looking forward to their input. But, he also cautioned, the wheels of government often turn slowly.

Dawson said he was impressed by the backgrounds of the council members, referring to them as some of the "who's who" in EMS. The panel is expected to make recommendations to Dawson's office on EMS stan¬dards, guidelines, bench¬marks and data collection. They also will offer advice on conducting a needs assess¬ment to improve prehospital care.

"We have a multidisciplined group that is willing to tackle the challenge," Gainor says. "We are fortunate to be able to draw on this expertise."

Gainor says she heard a common theme emerge after listening to the members introduce themselves:

"Every¬ one sees the need for safe, reliable, capable and accountable EMS systems."

NHTSA staff spent months reviewing more than 400 applications before selecting the council's members. Dawson said it was important that the group represent every aspect of EMS.

People not on the council may be asked to participate on committees. NEMSAC's next meeting is scheduled for July 17--18 at a Washington, DC, location to be determined. --Susan Nicol Kyle, EMSResponder.com

NEMSAC MEMBERSHIP

Those appointed to the council include:

• Charles Abbott, chief, Nevada Office of Traffic Safety; Western Region representative, Executive Board, Governors Highway Safety Association.
• Dia Gainor, MPA, state EMS director, Idaho.
• Kyle R. Gorman, MBA, EMT-P, executive officer, Clackamas County (OR) Fire District #1.
• Joseph Heck, DO, emergency physician; EMS medical director, Clark County, NV; Nevada state senator; vice chair, Transportation and Homeland Security Committee.
• Patricia Kunz Howard, PhD, operations manager, emergency and trauma services, University of Kentucky Hospital; EMS training coordinator, Lexington Division of Fire and EMS.
• Thomas Judge, executive director, LifeFlight of Maine.
• Kenneth R. Knipper, Kentucky state director, National Volunteer Fire Council; chair, NVFC EMS Committee.
• Kurt M. Krumperman, MS, senior vice president, federal affairs and strategic initiatives, Rural/Metro Corp.
• Baxter Larmon, PhD, MICP, professor of emergency medicine, Geffen School of Medicine, UCLA; founding director, UCLA Center for Prehospital Care.
• Jeffrey T. Lindsey, PhD, chief, Estero (FL) Fire Rescue; adjunct faculty, St. Petersburg College.
• Daniel E. Meisels, MPA, manager, EMS program planning and special projects, New York-Presbyterian EMS, New York, NY.
• Robert Oenning, E9-1-1 program administrator, state of Washington.
• Aarron Reinert, executive director, Lakes Region EMS, MN.
• John Sacra, MD, emergency physician; medical director, Medical Control Board, Tulsa and Oklahoma City, OK.
• Ritu Sahni, MD, MPH, medical director, Lake Oswego (OR) Fire Dept.; EMS medical director, state of Oregon.
• Jose Salazar, training officer, EMS battalion chief, Loudoun County (VA) Fire and Rescue Dept.
• Jeffrey P. Salomone, MD, FACS, asso¬ciate professor of surgery, Emory Univer¬sity School of Medicine; deputy chief of surgery, Grady Memorial Hospital, Atlanta.
• Richard A. Serino, chief, Boston EMS.
• Linda K. Squirrel, EMS special projects coordinator, Cherokee Nation; treasurer, founding president, National Native American EMS Association.
• Kevin Staley, MPA, director of medi¬cal services, Mecklenberg EMS, Charlotte, NC.
• Matthew Tatum, EMS coordinator, emergency manager, Henry County, VA.
• Chris D. Tilden, PhD, director, Office of Local and Rural Health, Kansas Depart¬ment of Health and Environment.
• J. Thomas Willis, firefighter/para¬medic, Lombard, IL.
• Gary L. Wingrove, government rela¬tions and strategic affairs, Gold Cross Mayo Clinic Medical Transportation, MN.
• Joseph Wright, MD, MPH, pediatric emergency physician, Children's National Medical Center, District of Columbia; professor of pediatrics, emergency medi¬cine and prevention/community health, George Washington University Schools of Medicine and Public Health.

Report Offers Solutions to ED Boarding

Backups in moving patients clog hospitals, delay EMS

Imagine a restaurant where diners come in, are seated, eat and then never leave. There they sit, the hours ticking by, lines for service getting longer, business grind¬ing to a halt because staff can't clear those occupied tables.

That's a good way to look at emergency department boarding. The practice of hold¬ing admitted patients in the ED because there are no open inpatient beds in which to put them is the primary culprit behind patient backups that lead to overcrowding and ambulance diversions, and all their negative consequences for patients.

Make no mistake, the harm of boarding is real. For EMS transport units diverted as a result, it means disruption and delay as ambulances race to ever-more-distant hospitals in search of an open ED. It can also mean offload waits, as crews get stuck because swamped ED staff can't readily assume care of patients. And of course, if you're injured or ill, delays in care--be they from ambulance diversion, boarding, or simply overwhelmed ED staff--can be dangerous indeed. Of almost 1,500 emergency physicians surveyed last year by the American College of Emergency Physicians (ACEP), half had personally encountered patients who'd suffered due to boarding. Even more alarming, more than 13% knew of patients who had died because of it.

"I don't think we've focused enough on the patient safety issues associated with boarding and crowding," says Sandra Schneider, MD, FACEP, chair of the Department of Emergency Medicine at Strong Memorial Hospital in Rochester, NY, and secretary-treasurer for ACEP's board of directors. "We know boarded patients have higher mortality rates, particularly if they're going to the ICU. We know their length of stay is increased. We know that their time to pain medicine is increased. We know their time to angioplasty or car¬diology intervention is increased. We've found that elderly people who are boarded have a four times increased likelihood of having to go to a nursing home. There's just nothing good about it."

With that recognized, though, how do we reduce the scourge of boarding? The good news is that there are answers. In a report released in April, Emergency Department Crowding: High-Impact Solutions, an ACEP task force identifies steps facilities can take to reduce boarding and its resulting ED over¬load and long waits.

The report's perspective: Boarding is not just an ED problem. It's a system problem that requires whole-hospital solutions, including wholesale changes in organiza¬tional culture.

"Imagine hospital care as an assembly line," explains Schneider, who was part of the task force. "If stuff is backing up into Step 2, it's usually because Step 3 isn't work¬ing well. It's not that Step 2 should work faster; it's that there's no exit. Europeans call this exit block, and that's a good term for it, because that's really what's happening."

In response, the report offers three primary recommendations, as well as numerous addi¬tional ideas. The first big concept is simply to get admitted patients out of the emergency department--to sections of the hospital that aren't ideal for them, if that's all that's avail¬able, or even into hallways or conference rooms. But, somehow, out of the ED.

Farming patients out to other sections of the hospital lets various departments each absorb smaller hits rather than one (the ED) enduring a large one. And in addition to free¬ing ED capacity, it likely means better care for these patients.

"The best place for a patient is on the floor, in a room, in a bed," says Schneider. "The next best place is on a floor where there's a nurse who's trained to take care of inpatients taking care of you. What's not good is staying in the emergency department, where you have a non-inpatient nurse taking care of you. There are errors that occur in the ED because ED nurses are not inpatient nurses. Our nurses are good at taking care of emer¬gency patients, but they're not good with things like complicated inpatient medicine regimes--that's not what they do. In the same way, inpatient nurses aren't good at doing emergency care. That's why you have specialty nurses."

For guidance in implementing this idea, readers are directed to www.hospitalovercrowding.com, a site operated by task force chair Peter Viccellio, MD, FACEP, clinical director of the emergency department at the Stony Brook University (NY) Medical Center. It contains numerous resources, including a model protocol for patient distribution in times of full capacity (see 'Next Most Appropriate').

The report's second recommendation is to discharge patients early in the day, so their beds can be turned around for incoming ED patients. Because the discharge process has grown so complex, authors note, this should occur by noon. In contrast, recent years have seen discharge times grow later in many hospitals.

The final idea is to better coordinate the scheduling of elective and surgical patients. Many hospitals have traditionally front-loaded these early in the week to facilitate follow-up care. They should instead be equally distributed throughout the week.

"One of the problems is having five-day-a-week hospitals in a seven-day-a-week economy," says Schneider. "If a person has a hip or knee replacement, for instance, it's often done on Monday, so they can have physical therapy on Tuesday, Wednesday, Thursday and Friday, because on Saturday and Sunday, there's no physical therapy. So they front-load patients who need physical therapy, who maybe are sicker, who need things like ICU care, to the beginning of the week. If you put those services in place seven days, then you end up with people who can actually be operated on all days of the week."

Here's where the culture change comes in. In many places, professionals like surgeons, physical therapists and occupational therapists don't work on weekends. Many hospitals reduce services and staff. Yet weekends and evenings can be high-volume times in EDs. Hospitals, the report concludes, must better match their resources to their volume, which is typically predictable.

Beyond its three "high-impact" solutions, the task force suggests a number of additional solutions. EDs can look at steps like:

• Elimination of triage, with patients put directly into beds and registered there.
• Fast-tracking the easy cases out of the main patient flow.
• Observation units for patients who may, with extended observation, avoid admission.• Use of scribes and other support staff.
• Deferring care of nonurgent patients to other facilities.

Many in the hospital world say EDs have largely done what they can. Boarding is truly an issue of throughput that involves a much broader spectrum of the hospital. It must be addressed as a system issue.

"What is necessary is a change in culture, and an acceptance that this is a hospital-wide problem, not an emergency department problem," says Schneider. "There are still people who believe that this is because we have too many uninsured people coming in to the EDs, or too many unnecessary visits. While there are a large number of those people, they really don't take up much time. They're not what causes overcrowding. Boarding causes overcrowding."

Emergency Department Crowding: High-Impact Solutions is available at www.acep.org.

Why Diversion Doesn't Work

One of the task force's conclusions was that going on ambulance diversion is not a good solution to the ED overcrowding boarding can cause.

"No. 1, it's bad for the patient," says Schneider. "It takes them to a hospital where they're not known and that doesn't have their records, and it increases both length of stay and cost, because they don't have access to previous x-rays and labs and may end up repeating studies."

Beyond that, experience has shown that once one hospital goes on diversion, others in the area quickly follow in the face of increasing patient volume.

"All it does is push this problem back onto EMS, increasing their costs and in some cases causing patient-safety issues," says Schneider.

'Next Most Appropriate'

Stony Brook University Medical Center's "full capacity" protocol:

"When a patient requires admission to an acute care unit from the emer¬gency department and that area can¬not accommodate the patient because of lack of sufficient beds, the patient will be admitted to the next most appropriate bed. In the event appropri¬ate hospital bed utilization has been maximized, and the number of admit¬ted patients holding in the Emergency Department has prohibited the evaluation and treatment of incoming patients to the Emergency Department in a timely fashion, the admitted Emergency Department patients already awaiting in house acute care bed assignments will be admitted to acute care unit hall beds."

WASHINGTON WATCH

Advocates to Host Federal Roundtable at EMS EXPO
Advocates for EMS will host a Federal Partners Roundtable at EMS EXPO this year in Las Vegas. The event will be held on Friday, Oct. 17 from 9:30--10:45 a.m. at the Las Vegas Convention Center in Las Vegas, NV.

FAA Taking Note As Medical Helicopter Crashes Continue
The FAA was taking a hard look at safety issues surrounding air-medical crashes even before the June 29 collision of two medical helicopters in Flagstaff, AZ, killed seven, bringing to 20 the number killed in such accidents since Dec. 30, 2007. Roughly a month before, a PHI Air Medical helicopter crashed near Huntsville, TX, killing four. That came on the heels of a Med Flight Wisconsin crash that killed Madison's EMS medical director.

While the Flagstaff incident occurred in the afternoon, four other recent deadly crashes happened at night, with pilots having no visual reference points on the ground. In 2006, the NTSB issued recommendations for flying at night and in poor weather, urging the use of night-vision goggles and technology to warn pilots flying too close to the ground, and that more attention be paid to risk factors like bad weather. The FAA has not made the recommendations mandatory.

Cochairs of New House EMS Caucus Seek More Members
Three members of the U.S. House of Representatives have agreed to cochair a new Congressional EMS Caucus: Reps. Dutch Ruppersberger (D-MD), Charles Boustany (R-LA) and Tim Walz (D-MN). They are now seeking additional members for the cau¬cus, which EMS advocates hope can help advance funding and legislation to benefit EMS.

Election-Year Politics Delay Key 2009 Appropriations Bill
Election-year politics took their toll on FY2009 legislative efforts as Congress worked to pass spending bills in the early part of the summer. A procedur¬al disagreement in the House of Representatives stalled one key appropriations bill before the Independence Day break, and it was uncertain when it might move forward.

The Labor, Health and Human Services and Education appro¬priations bill passed the Senate, with key EMS-related initiatives such as the Rural and Commu¬nity Access to AEDs, Traumatic Brain Injury and EMS for Chil¬dren programs funded at levels similar to FY08. In the House, however, once the bill emerged from subcommittee, a number of procedural votes resulted in it being pulled from consideration. Appropriations Committee chair Rep. David Obey (D-WI) threat¬ened to end the appropria¬tions process and force funding through a continuing resolution in the fall.

A $300 billion farm bill con¬ference report, passed over the president's veto, authorized a $30-million-a-year grant pro¬gram for rural fire and EMS. And just before press time, Congress overrode a veto of a bill to in¬crease Medicare ground ambu¬lance payments by 3% in rural areas and 2% in urban areas.

Appropriations committees from both chambers also marked up the FY09 Homeland Security Appropriations bill in June. For the latest developments, see www.advocatesforems.org.

EMSNetwork Website Debuts Public Affairs Clearinghouse
EMSNetwork.org has an¬nounced the EMS Public Affairs Clearinghouse, a one-stop source for news on relevant initiatives and happenings across the U.S. It will cover legislative propos¬als, administrative rule changes, new and innovative public rela¬tions activities and EMS infor¬mation from federal agencies. Users are encouraged to use the resource to support and repli¬cate desirable proposals in their communities.

Missouri Bill Will Establish Stroke, STEMI Care Network
With the passage of its "time-critical diagnosis" bill, Missouri became the first state to legisla¬tively create a statewide network of care for STEMI and stroke. The bill provides guidelines for es¬tablishing STEMI and stroke cen¬ters in a system that follows the trauma-care model. Data sug¬gests that patients transported to such centers survive at higher rates.

TRANSPORT PAYMENTS COULD BE CUT UNDER BENCHMARK PLANS
Medicaid measure designed to shift control to states
By G. Christopher Kelly

Medicaid reimbursement for both emergent and nonemer¬gent ambulance transports could be cut under a proposed rule that would let states offer "benchmark" Medic¬aid plans to some beneficiaries.

The proposed rule, authorized by the 2005 Deficit Reduction Act, would amend federal law to allow these benchmark plans in lieu of traditional coverage. They would offer limited coverage compared to current plans. The goal is to shift some of the costs of Medicaid to the states, but to give them more control over dispersal of the funds.

Of relevance to the EMS community is language that says, "A state may, at its option, amend its state plan to provide benchmark or benchmark-equivalent coverage to recipients without regard to the assurance of transportation to medically neces¬sary services requirement specified in section 431.53 of this chapter." Section 431.53 requires states to "ensure necessary transportation for recipients to and from providers."

In my opinion, this language in the proposed rule is unclear as it relates to limitations on the removal of coverage for transportation services. On its face, this appears to be a broad and sweeping reform that could cut reimbursement for all transporta¬tion services, both emergent and nonemergent. Section 440.335 of the proposed rule seems to support this reading. But it may also provide for coverage. That section identi¬fies five minimum requirements for state plan coverage, which are:

1) Inpatient and outpatient hospital services; 2) Physicians' services; 3) Laboratory and x-ray services; 4) Well-baby and well-children care; 5) Other appropriate preventive services, such as emergency services, as designated.

Therefore, while the proposed rule specifically allows states to limit transportation coverage, it also requires coverage of "other preventive services," which may include emergency transportation. Also, in the opening statements of the proposed rule, the limit on transportation is cited as being in line with private health insurance plans that don't offer nonemergency medical transportation, suggesting the intent is to only limit coverage of nonemergent transports.

One of the problems with the proposed rule's vague language is that states may come up with different interpretations, leading some to cover emergent ambulance services while others do not. (Similarly, the current Medicaid transport language from section 431.53, set forth above, has led some states to cover wheelchair services while others do not.) In any event, it seems clear that nonemergent transports may not be covered (or will at least be up to the states' discretion), while the future of emergent services under these new plans remains unclear.

There are a few mitigating factors to consider. First, it is possible the language of the proposed rule will be clarified in the final rule to expressly cover emergent services. Second, the number of states that will choose to adopt this new program remains unknown--bench¬mark plans are entirely optional. Third, the benchmark plans have minimum requirements, but states may also add other services and thus may continue to cover ambu¬lance transportation (both emer¬gent and nonemergent) even with benchmark plans. Finally, for states that create benchmark plans, not all Medicaid beneficiaries will qualify, and some who do may opt to stay with traditional Medicaid. There¬fore, there remains some question as to the final effect of the rule and the number of beneficiaries that will ultimately be enrolled.

Keep your eyes open for the final rule, and be prepared to discuss this at the state level with your state representatives and Medicaid officials, because while the federal rule may allow for limiting funds for ambulance services, the states have the final word on what will be covered by any benchmark plans they create.

G. Christopher Kelly is an attorney in Atlanta, GA. Contact him through EMS Consultants, Ltd., 800/342-5460, ckelly@emscltd.com.

FIRST NEMSIS REPORTS NOW AVAILABLE
National database up to 3.2 million care records and counting
By John Erich, Associate Editor

The field of prehospital care has never had a comprehensive national system with which to collect data from patient encounters. As a result, there's a lot we can't document about how well our efforts work. And that, EMS leaders will tell you, is no way to run a medical field.

The National EMS Information System (NEMSIS) is the first attempt to collect this patient data nationally. It will provide a database containing millions of records submitted by state and local agencies across the U.S., ultimately allowing comparison of results across systems and the benchmarking of quality prehospital emergency medical care."

The idea is to have a national registry that describes what EMS does," says Clay Mann, PhD, principal investigator for the NEMSIS Technical Assistance Center, the project's resource hub. "It will not only allow us to count resources available for emergency response--for example, how many ambulances there are, how many first responders, what their training is, what type of agencies they're associated with--but to also collect patient care data that will let us look at important issues in EMS education and research, and can help describe our reimbursement needs."

With the June release of the database's first set of national reports, it took a major step toward realizing that promise. Around 40 reports are now available on the NEMSIS website (www.nemsis.org, under NEMSIS Reporting/National Reports). They represent a current data set of roughly 3.2 million records drawn from 10 states.

That's only a fraction of what will eventually be available. All U.S. states and territories have agreed to contribute data, and the number doing so is increasing rapidly. By the end of 2006, three states were participating; now there are 11, and there should be 20 by the end of 2008.

All will use a core set of 83 data elements derived from NHTSA's Uniform Prehospital Data Set 2.2.1. To allow for a true comparison of apples to apples, all systems must measure the same things the same way. For some systems, this has meant a change.

"When we started, probably half of the states had some type of regional or state-level aggregation of data," says Mann, a professor of pediatrics at the University of Utah School of Medicine and director of research at the university's Intermountain Injury Control Research Center. "The problem was that the way the variables were defined differed from agency to agency, region to region, state to state. So the purpose of NEMSIS was to provide a standardized data set everybody could use for every EMS call in the country."

This also facilitates the work of software vendors, who no longer must build to hundreds of differ¬ent state and local standards. They have responded: Dozens of vendors whose products are compliant with NEMSIS requirements are listed at www.nemsis.org under Compliant Software.

This should ease the transition as state and local systems become NEMSIS-compliant. The project's advent also represents an oppor¬tunity, for those still on paper, to convert to electronic patient care reporting. Beyond simplify¬ing their contribution of data to NEMSIS, ePCRs improve the speed and accuracy of care documentation and generally make life easier for providers.

"This isn't like a national cancer registry, where you have people sitting in offices completing data from medical records," notes Mann. "These folks are collecting data in the field, while they're trying to care for patients. That's not an easy task."

As more states join the data stream, NEMSIS architects are already work¬ing at revising their data set in accordance with NHTSA's forthcom¬ing version 3.0. NHTSA's update process began this year and should be completed by 2010. Streamlined NEMSIS requirements will follow. But for now, the emphasis is on feeding the system and expanding its initial data mass.

"People have worked very hard with us over the last few years," says Mann, "and I think if we have a couple more years of that kind of dedication, we'll have a strong national registry that can answer a lot of questions that remain unre¬solved for EMS."

Doing Well, Doing Better
As well as contributing to the national EMS data collection effort, using new NEMSIS-compliant software is also letting EMS authorities in New Jersey compare and improve their squads' performances.

Working with Bethlehem, PA-based process-improvement consultant PeopleForce, the New Jersey State First Aid Council is standardizing response records and consolidating data for more than 200 state agencies using the Pervasive Data Integrator solution from Pervasive Software of Austin, TX. They're using a form available over the Internet to collect previously siloed data from responders across the state, which is then integrated and aggregated for retrieval and analysis.

The project has caught the eye of the U.S. Department of Transportation, which invit¬ed PeopleForce to show a blue-ribbon DOT panel how it can be a model for building consensus, creating meaningful metrics and reporting, and driving better accountability and document resource requirements for mutual aid agencies and funding reviews.

There are a growing number of software options available as systems move toward NEMSIS compliance. The NEMSIS Technical Assistance Center has certified more than two dozen products as Gold-level compliant, meaning they include all elements of NHTSA's 2.2.1 data set, and nearly three dozen more as Silver-level compliant, meaning they include key national elements being collected under NEMSIS, but not the entire 2.2.1 data set.

For more, see www.nemsis.org.

HELPING FREQUENT FLIERS
A novel program in Memphis reduces EMS' burden while bringing help to those in need
By Lt. J. Harold "Jim" Logan

All EMS systems have them. The tones sound, the dispatcher calls off the address, and immediately you know who it is, and you're reminded that emergency is a relative term defined by those who call 9-1-1. Their definitions don't always match yours.

One woman in our city called just about every day, sometimes twice. She'd been utilizing EMS as a gateway for healthcare and treatment for her mental illness for over 20 years. She'd racked up an estimated $12.9 million in ambulance and emergency department charges, and even been banned by several EDs in town. Everyone in the healthcare community knew her by name.

What this woman had really become over the years was a victim of the system. She became dependent on EMS as her entry point into the healthcare system. The ED was her source of primary healthcare, and she'd "hospital-shop" until she got what she needed. Over the years both her mental and physical health declined. She became noncompliant with the meds for her mental illness, which made her increasingly difficult to deal with. Eventually, people began to stop taking her seriously.

"Frequent fliers" like this woman utilize the safety net of EMS and the resources of emergency departments inappropriately. For emergency care systems burdened by such individuals, what's the answer? In 2005, the Memphis Fire Department created a first-of-its-kind program to help steer callers like this to resources more appropriate to help them. Its goal is to create awareness of alternatives to calling 9-1-1 with nonemergency requests for transport. Through it, we educate the community in the proper utilization of emergency medical services, and find repeat nonemergency callers other routes into the healthcare system. This decreases economic strain on the department and keeps our personnel and apparatus freer to help those with urgent problems.

According to firefighter/paramedic Mark Heaston, manager of the department's PIER (Public Information, Education and Relations) program, the 9-1-1 Alternatives campaign is extended to all consumers, both individuals and institutions, within the city who are identified as potentially needing nonemergency assistance but still call 9-1-1 for it. The process can be triggered by paramedics in the field who identify system misuse or through reviews of run data as part of regular quality improvement efforts. For example, if there is a response to the same address three or more times in a month, then contact is made with that individual (or institution; care facilities have been among the inappropriate users) to evaluate their true needs. If it's found the patient has nonemergency needs or could be better served with alternative resources, they are asked to work with providers to connect with them. Contact with a hospital caseworker is made, and the caseworker and fire department PIER manager begin locating resources to assist the person.

They work in conjunction with the CARE Team. The acronym stands for Community Awareness Reaching Everyone, and the team consists of hospital caseworkers assigned to area emergency departments, representatives of Adult Protective Services, and the Memphis Fire Department's 9-1-1 Alternatives program manager. This group works to customize assistance plans for those identified as utilizing emergency services for nonemergency needs. This process involves daily communication with outside agencies and the person in need. A primary focus is making sure all parties follow through with their assistance efforts, and facilitating communication and follow-up until the person is plugged into the proper resources for their needs and no longer misusing 9-1-1. Every day, this group discovers new resources and furthers relationships throughout the healthcare community, creating better ways to help its citizens.

Institutional misuse is addressed through regular visits by the PIER manager to nursing homes, clinics and other establishments from which nonemergency calls for EMS regularly originate. The visits are intended to educate the managers and staff to the purpose and proper use of 9-1-1. Sometimes, staff know no better than to call for things like routine nonemergency transports.

"We know we'll never get rid of the 9-1-1 callers who misuse the system," EMS Chief Gary Ludwig says. "We hope to target and control the most frequent misusers."

For more information, e-mail jim.logan@memphistn.gov.

FIRE-BASED SYSTEMS: BEST SUITED TO ADVANCE EMS?

A white paper released in 2007, titled Prehospital 9-1-1 Emergency Medical Response: The Role of the United States Fire Service in Delivery and Coordination, states that fire departments are best equipped to deliver emergency medical service. The report was written by Franklin Pratt, MD, medical director of the Los Angeles County Fire Department; Steven Katz, MD, associate medical director of Palm Beach County (FL) Fire Rescue; Paul Pepe, MD, Southwest Medical Center in Dallas; and David Persse, MD, City of Houston EMS physician director/Public Health Authority.

"The paper came about after some major fire organizations formed a coalition in September 2006 to address concerns about the ongoing effort by EMS advocacy groups to form a U.S. EMS Administration. This would move EMS responsibility from the agencies that currently have it into a single administration, which we feel is unnecessary," says Chief Dennis Compton of the International Fire Service Training Association. "There is also an effort to form an EMS Congressional caucus similar to the fire caucus, which we felt would confuse the federal agencies and congressional offices, because the fire service plays such a major role in EMS. We were concerned about private sector and hospital access to federal grant programs designated for the fire service, and we want to preserve that, and there were reports being produced that minimized the fire service's role in EMS."

The coalition, called Fire Service-Based EMS Advocates, consists of a steering committee that includes the International Association of Fire Chiefs, International Association of Fire Fighters, National Volunteer Fire Council, National Fire Protection Association and Congressional Fire Services Institute. Compton is a facilitator for the group. Membership is open to any organization or individual who agrees with the following statement of principle: "Fire service-based EMS systems are strategically positioned to deliver prehospital emergency medical services that incorporate time-critical response and effective patient care. Fire service-based EMS emphasizes responder safety, competent and compassionate workers and cost-effective operation."

"It's important to note that we're not advocating against any system," says Compton. "We're simply trying to better tell our story so the fire service-based EMS systems get the support they need."The steering committee has produced an eight-minute DVD describing the history and current status of the group that will be distributed with the white paper, says Compton. They are also writing articles, presenting at conferences and encouraging organizations to join their effort."We're going to work hard on the Congressional offices and federal agencies to inform them, advocate for our cause and gain their support for additional resources so that fire service-based EMS systems can become even more effective than they are today," says Compton.--Marie Nordberg, Associate Editor

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