Draft February 18, 2013 Comprehensive Emergency Medical Services Study Monroe County EMS Monroe County, NY FITCH & ASSOCIATES, LLC 2901 Williamsburg Terrace #G § Platte City § Missouri § 64079 816.431.2600 § www.fitchassoc.com CONSULTANT REPORT Monroe County EMS – Monroe County, NY Comprehensive Emergency Medical Services Study Table of Contents EXECUTIVE SUMMARY __________________________________________________________________________ 1 PROJECT DESCRIPTION ___________________________________________________________________________ 1 FINDINGS ____________________________________________________________________________________ 1 Governance of EMS in Monroe County Is Very Weak ______________________________________________ 1 EMS in Monroe County Does Not Operate As a System ____________________________________________ 1 The Closest Ambulance Is Often Prohibited From Responding _______________________________________ 2 Emergency Medical Care Is Not Consistent ______________________________________________________ 2 Slow Response Times Occur Throughout the System ______________________________________________ 2 Reliable Data Is Lacking _____________________________________________________________________ 2 Medical Directors Do Not Track Basic Clinical Performance _________________________________________ 3 Appropriate Interface with Hospital Emergency Departments Is Lacking ______________________________ 3 Monroe County Is More Urban than People Think ________________________________________________ 3 Fewer Ambulances Can Achieve Performance Metrics _____________________________________________ 3 RECOMMENDED OPTIONS FOR CHANGE _______________________________________________________________ 4 Option Zero: Retain the Existing Emergency Medical System _______________________________________ 4 Option One: Staged Steps Toward Higher Performance ____________________________________________ 4 Option Two: Implement The “M-xR” Model Using Existing Agencies __________________________________ 6 Option Three: Implement The “M-xR” Model Using a Contract Agency _______________________________ 7 METHODOLOGY _______________________________________________________________________________ 8 AREA OVERVIEW _______________________________________________________________________________ 9 DEMOGRAPHICS INTRODUCTION ____________________________________________________________________ 9 EMS DEMOGRAPHIC ENVIRONMENT ________________________________________________________________ 11 Historical Population Changes _______________________________________________________________ 14 Predicted Population Changes _______________________________________________________________ 16 DEMAND FOR EMERGENCY MEDICAL SERVICES _________________________________________________________ 17 MONROE COUNTY SYSTEM _____________________________________________________________________ 19 SYSTEM DESCRIPTION ___________________________________________________________________________ 19 CURRENT EMS GOVERNANCE STRUCTURE _____________________________________________________________ 21 Monroe-Livingston Regional EMS (MLREMS) ___________________________________________________ 21 EMS Program Agency ______________________________________________________________________ 22 Regional Emergency Medical Advisory Committee (REMAC) _______________________________________ 22 Technical Advisory Groups __________________________________________________________________ 22 County EMS Office ________________________________________________________________________ 22 County Medical Director ___________________________________________________________________ 23 EMS AGENCIES _______________________________________________________________________________ 24 Monroe County, NY © Fitch & Associates, LLC Comprehensive Emergency Medical Services Study Page i February 18, 2013 FIRE FIRST RESPONDERS _________________________________________________________________________ 29 SYSTEM DATA ________________________________________________________________________________ 34 Data Deficiencies _________________________________________________________________________ 34 CALL VOLUMES _______________________________________________________________________________ 35 BUILT-IN INEFFICIENCIES _________________________________________________________________________ 37 CALL PROCESSING ATTRIBUTES AND STANDARDS_________________________________________________________ 39 DISPATCH AND EMS AGENCY RESPONSE TIME PERFORMANCE ______________________________________________ 41 Dispatch Time ____________________________________________________________________________ 41 Agency Processing Time ____________________________________________________________________ 42 Chute Time ______________________________________________________________________________ 44 En Route Time ____________________________________________________________________________ 45 Total Response Time ______________________________________________________________________ 45 MUTUAL AID AND NEW YORK CERTIFICATES OF NEED _____________________________________________________ 52 CURRENT COUNTY MUTUAL AID PLAN _______________________________________________________________ 53 Innovative Nursing Home Mutual Aid Plan _____________________________________________________ 53 CALL COVERAGE ISSUES _________________________________________________________________________ 54 CLINICAL VISION/MEDICAL DIRECTION ____________________________________________________________ 55 QUALITY MANAGEMENT _________________________________________________________________________ 55 MEDICAL DIRECTION ISSUES AND OPPORTUNITIES ________________________________________________________ 56 Multiple Layers/Little Authority ______________________________________________________________ 56 Clinical Performance Is Not Measured ________________________________________________________ 56 Patient Care Reports Not Provided to Emergency Department _____________________________________ 57 Clinical Data Deficits_______________________________________________________________________ 57 Role of Full-Time County Medical Director Limited _______________________________________________ 57 HOSPITAL SURGE CAPACITY _______________________________________________________________________ 58 PATIENT DESTINATION REVIEW ____________________________________________________________________ 59 ALTERNATIVE DESTINATION OPPORTUNITIES ___________________________________________________________ 59 FUTURE INVOLVEMENT WITH RHIO _________________________________________________________________ 61 SYSTEM FINANCES ____________________________________________________________________________ 62 DUPLICATED FUNCTIONS AND COSTS ________________________________________________________________ 62 BENCHMARKING THE MONROE SYSTEM __________________________________________________________ 64 SYSTEM BENCHMARKING ________________________________________________________________________ 64 CLINICAL BENCHMARKING ________________________________________________________________________ 67 911/MEDICAL COMMUNICATIONS __________________________________________________________________ 68 Best Practice Benchmarks for Communications _________________________________________________ 68 Key Accomplishments and the Current Situation in Monroe County _________________________________ 69 Automatic Vehicle Location (AVL) and Global Positioning Systems (GPS) _____________________________ 70 CAD to Mobile Data Terminals _______________________________________________________________ 71 Electronic Patient Care Records (ePCR) ________________________________________________________ 72 911 Emergency Call Processes and Standards___________________________________________________ 72 Dispatch Personnel ________________________________________________________________________ 76 SPECIFIC AREAS FOR IMPROVEMENT _____________________________________________________________ 77 Monroe County, NY © Fitch & Associates, LLC Comprehensive Emergency Medical Services Study Page ii February 18, 2013 SOLUTIONS TO ALLOW FOR AGENCY BACKFILL __________________________________________________________ 77 IMPROVING EMS SUPPORT TO LAW ENFORCEMENT, FIRE AND SPECIAL OPERATIONS ________________________________ 77 BUILDING AN INCIDENT COMMAND STRUCTURE _________________________________________________________ 78 THE OPTIMIZED MODEL SYSTEM _________________________________________________________________ 80 GEOGRAPHIC AREA (M-XR) ______________________________________________________________________ 80 Operating Environment ____________________________________________________________________ 81 Historic Demand for Service _________________________________________________________________ 81 Defining Incident Zones ____________________________________________________________________ 83 Locating Ambulance Stations ________________________________________________________________ 85 Sizing the Fleet ___________________________________________________________________________ 89 IMPLEMENTATION OF M-XR AS OPTION TWO __________________________________________________________ 91 Estimate of Costs _________________________________________________________________________ 91 Comparison to the Existing System ___________________________________________________________ 92 Estimates of Revenues _____________________________________________________________________ 93 FINANCIAL OUTCOME OF M-XR MODEL ______________________________________________________________ 95 “IMPLEMENTATION” OF M-XR AS OPTION THREE ________________________________________________________