EMS Tiered Systems - Not Always a Good Idea

Imagine Firefighter/Paramedic Christopher Crockett rushes a patient to an emergency room with critical injuries from an auto accident. He has done everything humanly possible within the scope of his paramedic license, but as he rushes into the trauma room, he finds out that the emergency room is staffed only with nurses and no doctors. The nurses can only do so much. They cannot do some of the more advanced procedures and surgical interventions that will save Christopher's patient. Unfortunately, the patient dies waiting for a doctor to show up from another hospital. If only a doctor were present, things might have turned out different.

EMS tiered systems are no different. The first person treating a critically ill or injured patient could be an EMT unable to deliver advanced care.

Conducted studies that were published in the Annals of Emergency Medicine in 1989 and 1993 showed that for each minute that goes by, the mortality rate of a critically ill or injured person drops by about 10%. These studies have been validated subsequently by other studies and are especially true in a cardiac arrest.

There are all kinds of EMS tiered systems. Some use engines or two-person non-transporting squads as first responders that provide basic life support (BLS) and ambulances that are advanced life support (ALS). Others use engines or two-person non-transporting squads as ALS first responders and the ambulances are BLS. Still others use a mixture of BLS and ALS first responders and a mixture of ALS and BLS ambulances.

Many times, these configurations are driven by cost or a lack of paramedics. Running an all-ALS system can be very expensive, since each piece of response equipment must have monitor-defibrillators and other ALS equipment. Also, paramedics usually are paid at a higher rate than EMTs.

Many EMS systems run ALS and BLS ambulances. This delivery of a mixture of ALS and BLS ambulances in an EMS system can be a dangerous shell game, especially with a sizeable geographic area.

First, you're assuming the dispatcher was able to retrieve the correct information and determine whether a BLS or ALS response is required. As you know, what you are dispatched on many times and what you find when you get there does not always match, even with criteria-based dispatching systems. If you use a criteria-based dispatching system, and you have quality assurance personnel in communications who review 911 calls for compliance, ask them what their compliance rate is regarding the accuracy evaluation of 911 calls. I doubt you will find it is 100%.

Second, when you have a mix of BLS and ALS ambulances, an ALS ambulance may not be the closest ambulance to a critical call. It may be a BLS ambulance. Who do you send? The BLS or ALS ambulance? If you send the BLS ambulance, it will do the patient no good since studies have shown an approximate 10% mortality rate for critical patients for each minute that goes by without ALS intervention. If you send the ALS ambulance, it is farther away and treatment is delayed even more. If you send the BLS and ALS ambulance, now you have two ambulances tied up on the same call. This makes no sense.

Another tiered model puts EMTs on all the ambulances and paramedics on engines. On critical calls, the paramedic could ride to the hospital with the two EMTs and the ambulance. The problem is this: Since most fire departments have more engines than ambulances, you will need more paramedics to completely staff all engines on all shifts. Additionally, do not forget the National Fire Protection Association (NFPA) 1710 standard, which indicates two paramedics should be on the scene of all ALS calls. This is should be the goal of all fire departments that provide ALS service.

Finally, if you are comfortable with a tiered system, let me give you something to think about: Why not apply the principle to fire suppression? Not every call requires a big engine hooking up to a hydrant to pump water. Get rid of half of your department's engines and ladders and put two-person mini-pumpers with 150-gallon booster tanks in their spots. After all, most fire-related calls (alarm soundings, sprinkler alarms and smoke detectors sounding) do not require large volumes of water and when water is needed, it is usually a booster for a car, weeds or a dumpster.

Obviously, does not make sense, just like an EMS tiered system does not make sense in most communities. Response times, staffing and delivery levels are key components to the outcome. Playing a guessing game with EMS delivery is risky.