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JOINT LEGISLATIVE AUDIT AND REVIEW COMMISSION OF THE VIRGINIA GENERAL ASSEMBLY Review of Emergency Medical Services in Virginia House Document No. 37 (2004) Members of the Joint Legislative Audit and Review Commission Chairman Delegate Lacey E. Putney Vice-Chairman Senator Thomas K. Norment, Jr. Delegate Vincent F. Callahan, Jr. Senator John H. Chichester Senator Charles J. Colgan Delegate M. Kirkland Cox Delegate H. Morgan Griffith Delegate Frank D. Hargrove, Sr. Delegate Johnny S. Joannou Delegate Dwight C. Jones Delegate Harry J. Parrish Senator Walter A. Stosch Delegate Leo C. Wardrup, Jr. Senator Martin E. Williams Mr. Walter J. Kucharski, Auditor of Public Accounts Director Philip A. Leone © 2004, Commonwealth of Virginia Preface House Joint Resolution 133 of the 2004 General Assembly called for the Joint Legislative Audit and Review Commission (JLARC) to conduct a comprehen• sive review of pre-hospital emergency medical services (EMS) in Virginia. The man• date directed JLARC staff to address several broad areas, such as reviewing and as sessing emergency care services in Virginia, identifying emerging issues and prob lems in the EMS system, and considering the effect on the EMS system of issues such as health care costs, funding for emergency medical care, and third-party reim• bursement. JLARC staff found that Virginia’s EMS system is currently in a state of transition. Training requirements for EMS staff are increasing, and in many areas of the State, EMS is moving from a free service provided by volunteers to a service that bills for the care it provides and uses paid staff to ensure the availability of a high level of emergency medical care 24 hours a day, seven days a week. Overall, this report found that all Virginians have access to some level of emergency medical services. However, the availability of advanced life support pro• viders, particularly paramedics (the highest skill level of EMS provider), varies sub• stantially across the State. The time it takes for an ambulance to respond to a 911 call also varies across the State; response times are longer in some parts of the State due to factors such as terrain, population and traffic densities, and EMS agency staffing levels. Other issues are also affecting the EMS system. For example, agencies are having difficulties recruiting and retaining providers, both volunteer and paid. Ac• cess to advanced life support training has been reduced because of new accreditation requirements. In addition, many EMS agencies do not bill patients’ health insur• ance for emergency medical services, forgoing a substantial revenue source. This report makes several recommendations to address these issues, includ ing amending the Code of Virginia to require local governments to ensure the provi• sion of EMS, requiring EMS agencies to have response time goals, requiring new squad captains to take leadership and management training to improve recruitment and retention, improving access to advanced life support training, and encouraging agencies to bill patients’ health insurance for services. Several organization and management recommendations are also presented to help improve services. On behalf of the JLARC staff, I would like to thank the staff of the Office of Emergency Medical Services in the Department of Health, and the local EMS agen cies and providers that provided assistance during our review. Philip A. Leone Director November 15, 2004 JLARC Report Summary Pre-hospital emergency medical ser­ vices are a large and critical part of Virginia’s health care system. Virginia’s EMS provid ers reported more than 1.3 million re­ sponses to emergency medical incidents during the 2002-2004 biennium, according to data maintained by the Virginia Depart­ ment of Health’s Office of Emergency Medi cal Services (OEMS). Nearly 33,000 people REVIEW OF are certified to provide emergency medical care in 815 licensed EMS agencies located EMERGENCY MEDICAL throughout the State. Emergency medical services in Virginia SERVICES IN VIRGINIA are in transition. Training requirements for EMS staff are increasing, and in many ar­ eas of the State, EMS is moving from a free November 2004 service provided by volunteers to a service that bills for the care it provides and uses Joint Legislative paid staff to ensure the availability of a high Audit and Review level of emergency medical care 24 hours a Commission day, seven days a week. Public expectations for emergency medical care tend to be high. A 1999 VCU Commonwealth Poll found, for example, that 59 percent of the respondents said they would expect a paramedic, the highest skill level among EMS providers, to provide care in response to an emergency in their home. House Joint Resolution 133 of the In reality, however, only ten percent of all cer­ 2004 General Assembly calls for the Joint tified providers are paramedics. The same Legislative Audit and Review Commission poll found that 55 percent of the respondents (JLARC) to conduct a comprehensive re­ rated the quality of the emergency medical view of pre-hospital emergency medical care in their community as excellent or good. services (EMS) in Virginia. The mandate Virginia’s EMS system is well above the lists several broad areas the study is to ad­ national average in the number of emergency dress, such as reviewing and assessing medical vehicles and personnel relative to emergency care services in Virginia, identi­ the population served. In 2003, the Com­ fying emerging issues and problems in the monwealth was ranked first in the nation in EMS system, and considering the effect of the ratio of population per emergency ve­ issues such as health care costs, funding hicle, with one vehicle for every 1,749 resi­ for emergency medical care, third-party re­ dents, and tenth in the ratio of population per imbursement, and indigent care on the EMS certified EMS personnel, with an average of system. one certified EMS provider for every 215 I people. These excellent national rankings priate facility within the first hour after the do not mean that vital EMS resources are incident (the “golden hour”). uniformly distributed within the State; in fact, All localities have access to some level the ratio of providers to population varies of EMS, although 53 percent of all Virginia from a high of one provider for every 70 paramedics (the highest skill level of EMS people in Surry County to a low of one pro- provider) are in just 14 localities, and 12 lo- vider for every 1,211 residents in Manassas. calities have no paramedics. Overall, most In 2003, the average reported time re- EMS providers are located in the State’s quired for a unit to arrive on scene after it major population areas (see map below). was dispatched was approximately 12 min- In many areas of the State, EMS is utes, and 72 percent of all reported re- available only because individual residents sponses were provided in less than 10 min- have volunteered and organized themselves utes. Less than one percent of the reported to provide the services – there is no State responses took more than one hour from requirement for EMS to be available. While the time the unit was dispatched until it ar- State law directs the Board of Health to de- rived on scene. This analysis is, however, velop a comprehensive and coordinated based on a review of the limited data on re- system of EMS, no agency, either State or sponse times, as at least 200 EMS agen- local, is required to actually provide emer- cies did not submit this data to OEMS as gency medical services. Local governments required by law. provide EMS in 84 localities, but have played There are places in Virginia where re- only a minimal role in other areas. For ex- sponse times may be longer, due to a com- ample, 18 localities (13 counties, three cit- bination of factors such as terrain, popula- ies, and two towns) were reported as hav- tion and traffic densities, and EMS agency ing provided less than $10,000 in financial staffing levels. This is important because support to the volunteer EMS agencies op- the patient’s chance of surviving major inju- erating within their jurisdictions, according ries is much greater if treated at an appro- to grant applications filed by the agencies. Total EMS Providers in Virginia Localities State Average = 239 Providers per Locality Bottom Ten Below Average Above Average Top Ten II As shown in the table below, there are vital public service, like firefighting and law 485 EMS agencies classified as volunteer enforcement. Moreover, the public appears agencies. Some localities are totally depen­ to expect a high level of emergency medical dent on these volunteer agencies for EMS. service, in which an ambulance staffed with Virginia is fortunate to have such extensive highly-trained medical personnel arrives participation by volunteers, especially when within minutes of a call to 911. In many there is no State mandate for EMS. Among places in Virginia, reality meets these high the 84 EMS agencies operated by local gov­ expectations. ernments, some rely on full-time employees Because of the lack of a State law, how­ to provide services, while others use a com­ ever, it is unclear who is supposed to take bination of career EMS providers alongside corrective action when EMS services are volunteer providers. Several localities also inadequate or unavailable. There is no statu­ contract with private firms for EMS. While tory requirement for any entity to ensure many EMS agencies appear to provide a continuity of services when volunteer agen­ reasonable level of emergency care, there cies close or disband, as four did in FY 2003 are several actions that should be taken to and FY 2004. In each of these cases, local improve and strengthen the system state­ government EMS agencies assumed re­ wide.

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