Change in FDNY Paramedic rules.
Jan 6, 2005
Author: FDNYEMSwebsite@aol.com

FDNY wants to change paramedic rules.

The New York City Fire Department is requesting permission to go to single Paramedic units in NYC. This will lower the standard of care given to all New Yorkers by the members of FDNY EMS. One Paramedic cannot effectively perform all of the complicated tasks that are required in a major medical emergency as two paramedics. The care that would be given to all New Yorkers would be compromised. Here is the Fire Departments request. What do you think?

Fire Department City of New York
Phone: 718-999-2770
9 Metrotech Center Fax: 718-999-0112
Brooklyn, NY 11201

Maximizing ALS Response
A Proposal to Change the ALS Staffing Requirements


FDNY's Plan to Maximize ALS Response
A Change to the REMAC ALS Staffing Standard

Introduction

The New York City "911" EMS system responded to 1,109,287 requests for EMS assistance during calendar year 2003. Of these, 402,652 were categorized as potentially life threatening medical emergencies (priorities 1 through 3) through the use of EMS dispatch prioritization algorithms. Furthermore, 329,914 of these were determined to require the response of an Advanced Life Support unit.
During 2003, an average of 315 Advanced Life Support (ALS) tours (34%) were fielded daily of the 922 total tours fielded.
The Problem
Ideally 100 percent of patients who have medical conditions that would potentially benefit from ALS would receive an ALS ambulance to the location rapidly. Our goal has been to have an ALS ambulance on the scene in less than ten minutes.
According to statistical reports compiled by FDNY, only 96% of the nearly 330,000 ALS calls were assigned an ALS unit. That means that over 13,000 potentially life-threatening assignments that required ALS units did not receive one.
Only 81% of the ALS recommended assignments received an ALS ambulance on-scene within 10 minutes. It took 12 minutes and 31 seconds for an ALS unit to get to 90% of all ALS recommended assignments.
The stated goal for FDNY is to have 90% of ALS assignments to receive an ALS ambulance on-scene under 10 minutes.
Current State of ALS Response in the NYC 911 System
There is a shortage of paramedics, both in the City and throughout the Nation. Recent articles in national EMS journals (JEMS, EMS Insider, EMS Magazine, etc.) describe that every major city is having difficulty recruiting paramedics. There are discussions, at both the State and Federal levels, questioning the impact of the training curriculum on paramedic staffing.
This shortage of paramedics is taking its toll on staffing in NYC, and the Department is having difficulty recruiting trained personnel. The Department has employed the following strategies to increase the number of ALS units to respond to ALS calls:
1) A nationwide advertisement campaign to hire paramedics,
2) A scholarship program to pay EMTs employed by the Department to attend paramedic programs to upgrade members to paramedic status.
3) A review of current ALS responses to ensure that ALS units respond to the most appropriate calls,
4) An increase in the number of Voluntary ALS units participating in the 911 System, and
5) Reinstatement of the full time paramedic program to train members to become paramedics.
Even with all of these efforts, the Department is unable to achieve the goals for ALS units to ALS recommended assignments, and will not be able to in the near future.
It is estimated that an additional 100 ALS tours are needed to achieve the ALS response goals. With current ALS staffing requirements (two paramedics per ALS ambulance), it will take more than seven years to sufficiently increase the numbers of paramedics available to staff enough units to achieve these goals.
ALS Staffing Arrangements
Since 1974, the City has utilized Advanced Life Support (ALS) ambulances to enhance the level of pre-hospital medical care that can be provided to the public. The current REMAC ALS staffing standards have guidelines for the provision of ALS care for both 911 generated calls and non-911 generated calls. Currently two EMT-P's per ALS unit are required for 911 generated calls.
Throughout the country there is no set staffing level of ambulances. Below are some examples of staffing levels that are seen in the industry:
1) One EMT and one chauffer,
2) One or two EMTs,
3) One Advanced Emergency Medical Technician-Critical Care who is met by a police escort who drives the ambulance from the scene,
4) Two Emergency Medical Technician-Intermediates,
5) One paramedic and one EMT,
6) One Emergency Medical Technician-Intermediate and one paramedic, or
7) Two paramedics.
There is no published data that shows improved clinical effectiveness by ALS ambulances that are staffed with two paramedics.
The NYC REMAC has previously discussed changing the staffing requirements for 911-ALS ambulances. The most recent TAG to put forth recommendations on this topic was chaired by Dr. Kevin Brown (dated 5/7/2000. It is now clear that changing the staffing requirements would allow for substantial benefits to the 911 EMS system (as stated above).
A Three Pronged Approach
The Department is proposing a three-pronged approach to changing the staffing standard. This approach was designed so that some needs could be addressed immediately while allowing for discussion of other points that may be more involved. The three-pronged approach includes:
1. Allow for staffing of ALS Units with one paramedic and one EMT when a disaster occurs or there is a significant threat of an impending incident that may require a sizeable increase in ALS resources.
2. Allow for the staffing of ALS First Response Units (ALS-FR) with one paramedic and one EMT.
3. Allow for the staffing of ALS transport units with one EMT and one paramedic.
The Department requests that the Regional Emergency Medical Advisory Committee approve all three of these standards; however, each standard should be evaluated on its own merit so one isn't delayed pending discussion of the remainder.
Disaster Response/Terrorism Response
Large Scale Multiple Casualty Incidents (MCI) can strain the resources available to the point where the mission of providing pre-hospital care cannot be accomplished. For ALS response, this means that there will not be sufficient ALS resources to respond to the disaster and the normal 911 calls received. In times of MCIs, the Department needs to field additional ALS Units to handle the increased demand. Because of the limited supply of paramedics, the only alternative available to the Department is to modify the staffing requirement. Also, when the Department receives credible threats, additional units may be staffed to ensure proper response.
The Department will make a decision based on the capability of the system to provide ALS resources to the incident, the nature and credibility of the threat, and the availability percentage of ALS units in the "911" system.
First Response ALS Units
The Department is currently reviewing plans to deploy specialized ALS First Responder Units. These units would be staffed with one EMT and one Paramedic. These units would be assigned to incidents where specialized training may be required to access patients and provide appropriate treatment unusual circumstances. These incidents include, but are not limited to: collapse, contaminated environment, and high-angle rescue.
Normal "911" Ambulance Units
In light of the staffing difficulties discussed and the need to increase ALS resources in order to achieve performance standards already established, the FDNY is seeking to increase ALS resources through implementation of a modified staffing model.
A portion of the ALS ambulances in the 911-system would be staffed with one EMT and one Paramedic. These units would be assigned to ALS assignments and when necessary, would receive an additional ALS resource consisting of a traditionally staffed ALS unit, an ALS-FR unit or another single medic ALS unit.
Presently, the FDNY requires that its paramedics complete a 960 hour field internship before being permitted to work with one another. All Paramedics on these single-medic ALS units would have successfully completed this internship.
Traditionally staffed ALS units would continue to operate and be staffed with two Paramedics. A portion of these would be utilized as training units for paramedic field internships.
Protocol Review
The NYC REMAC allows for the use of Advanced Life Support Protocols for five different staffing models:
1) An ALS Service, operating in the 911 System, staffed by two paramedics,
2) An ALS Service, not providing care in the 911 System, staffed with a paramedic and an EMT,
3) An ALS Service, not providing care in the 911 System, staffed with one EMT-CC and one EMT.
4) A BLS service that operates with ALS personnel, providing limited ALS care.
There is no difference between the protocols used by a two paramedic unit operating in the 911 System and a single paramedic unit responding to calls outside the 911 System. There is no difference between the care provided by a single paramedic operating for a BLS service and the current care provided by a single paramedic operating on a BLS unit in the 911 system. The only staffing model with any difference between protocols is the dual paramedic and the single EMT-CC. The EMT-CC protocols use the skill set and formulary. The only difference between the EMT-CC and paramedic protocols is the point in the protocols when contact with medical control is required.
Based on this review of protocols used by all providers and the knowledge base of the paramedic, there is no adjustment to the current protocols needed in a single paramedic system.
Quality Assurance Review
As each component of the plan is implemented, the Department will conduct a Quality Assurance review to ensure that quality of care is maintained. Some specific areas to monitor may include:
1) ALS response time and the fractal ALS response time.
2) On-scene times.
3) Patient condition upon transport.
4) Successful completion of ALS interventions.
These markers would be under constant review to determine if the program is succeeding. Any negative indicators will be analyzed and the program will be adjusted for improvement.
Summary
The FDNY is evaluating our performance objective as it relates to ALS assignments and would prefer evaluating performance based upon the ability of an ALS unit to respond an ALS assignment 90% of the time in under 10 minutes. For 2003, 81% of the time an ALS unit responded to an ALS call in under 10 minutes. To achieve this goal, roughly 100 additional ALS tours would be necessary.
Present staffing requirements call for two paramedics to staff an ALS unit, this would require nearly 400 additional paramedics.
Because of the shortage in paramedics, the need to increase our ALS response capability, and the lack of evidence supporting any staffing model, the Department is requesting a change in the ALS staffing requirement.
By approving and implementing these proposals in a coordinated and controlled manner, we believe that the number of ALS tours could be increased and that the performance standards discussed could be achieved in a timely manner.