From Worst to First?

Washington, D.C., overhauls its EMS system

• Mannie Garza
• January 2009 JEMS Vol. 34 No. 1
• 2009 Jan 1

Can our nation’s capitol transform its EMS system from what  USA Today declared in 2003 to be the nation’s worst EMS system into a model for systems nationwide? Washington, D.C., is now moving forward with an ambitious plan to accomplish just that goal.

The blueprint for this transformation was provided by a task force created in response to a lawsuit filed by the family of  New York Times  journalist David Rosenbaum. Rosenbaum died after he was mugged on a D.C. street in January 2006 and fell victim to a series of errors by District of Columbia Fire & EMS (DCFEMS) EMTs and staff at the hospital where he was taken. Among other things, the lawsuit claimed DCFEMS EMTs missed Rosenbaum’s head injury because they assumed his symptoms were the result of being drunk and bypassed the closest appropriate hospital to take him to a facility more convenient for one EMT to take care of personal business.

The Rosenbaum family agreed to drop its $20 million lawsuit if the city convened a task force to undertake a top-to-bottom look at the city’s EMS system and then implemented the task force recommendations for improvement. 

In January 2007, Adrian M. Fenty became the city’s new mayor, and former Atlanta fire chief,  Dennis Rubin , took the helm of DCFEMS. Both vowed to turn the city’s EMS system into “a world-class service.” 

In April 2007, the city created a 13-member EMS Task Force. In September 2007, the EMS Task Force released six broad recommendations and 50 action items to flesh out those recommendations. 

Task Force Recommendations
The task force’s primary   recommendations were:

>> Transition DCFEMS to a fully integrated all-hazards agency;

>> Reform the department’s structure to elevate and strengthen the EMS mission;

>> Improve the level of compassionate, professional, clinically competent patient care through enhanced training and education, performance evaluation, quality assurance, and employee qualifications and discipline;

>> Enhance responsiveness and crew readiness by revising deployment and staffing procedures;

>> Reduce misuse of EMS and delays in patient transfers; and

>> Strengthen Department of Health oversight of EMS.

During his mayoral campaign in 2006, Fenty promised to address problems within DCFEMS by separating EMS from the fire department. But the task force didn’t include that as one of its suggestions. Instead, the panel offered two major proposals designed to improve the role of EMS within the DCFEMS structure, culture and capabilities: Strengthen EMS leadership within the department and cross-train fire and EMS personnel to create “a fully integrated, all-hazards agency.” (See “D.C. to Crosstrain Staff: Task Force on EMS makes recommendations,” December 2007  JEMS .) 

“I was the only person [on the panel] who didn’t support all the recommendations,” says task force member Richard Serino, chief of Boston EMS, which has produced some of the best patient outcomes in the nation. “Good work was done, but it could have been better. This provided a golden opportunity for D.C. to have one of the best EMS systems in the country, but the recommendations didn’t go far enough.”

Each recommendation requires accomplishing two to 24 action items. The DCFEMS EMS Working Group has met weekly since September 2007 to guide implementation of the recommendations and action steps, and the department’s Web site (http://fems.dc.gov) provides a running tally of progress on each item. 

As of May 2008, DCFEMS reported it had completed 27 of the 50 action steps and work was underway on 21 more. As of Oct. 1, the tally was the same, but information had been added detailing how work on some of the as-of-yet completed recommendations was proceeding.

New EMS Leadership
To achieve the second recommendation, DCFEMS had to appoint a medical director (at the rank of assistant fire chief) who would report to the fire chief, but who could be removed only by the mayor. Last summer, Rubin recruited Atlanta Fire & Rescue’s medical director (and  JEMS  editorial board member)  James Augustine , MD, who is now the department’s acting medical director and assistant chief. “Few communities have had the opportunity for a complete redesign and rebuild of its EMS system,” says Augustine.

The task force also recommended creating new positions for EMS battalion chiefs and more EMS captains to improve 24/7 EMS supervision and create an enhanced EMS career ladder. DCFEMS responded to this recommendation by completely overhauling its EMS supervisory structure. 

Before the restructure, four supervisors at the rank of lieutenant and one shift supervisor at the rank of captain provided all EMS field supervision. The department now has eight on-duty EMS field supervisors and a ninth who works in the communications center. 

“All EMS supervisory positions have been reclassified to provide additional authority and increased pay,” says Acting Assistant Chief for EMS  Rafael Sa’adah , NREMT-P.

DCFEMS now also has an EMS supervisor for each of its six geographic battalions and for a seventh citywide special-operations battalion, and they work the same shifts as the firefighters. 

“Previously, EMS supervisors worked different shifts than fire officers and the dual-role firefighters who comprise the vast majority of our EMS workforce, creating a de facto bifurcation within our operational chain of command,” Sa’adah says. Now, a unified battalion management team led by a battalion fire chief and an EMS battalion supervisor (a captain) manage each battalion’s operations. 

Although, as captains, the EMS supervisors are ranked below the battalion fire chief, Sa’adah insists, “We don’t see this as a subordinate position; they work as a team.” 

“The feedback from both groups of officers has been overwhelmingly positive,” Sa’adah says. “They appreciate the continuity of working with the same person each day, and I think the EMS supervisors feel more empowered and less alienated than before.”

Before the restructuring, fire officers—but not EMS supervisors—competed for promotions via a biannual promotional process. “EMS promotions were somewhat subjective,” he says. 

To remedy that situation, the DCFEMS EMS Working Group engaged a wide cross-section of the department in developing a competitive process for promotion to EMS supervisor. The department plans to offer the new promotional exam this winter.

“For the first time, all eligible members can compete for these positions,” Sa’adah says. Incumbent single-role EMS supervisors must only pass the exam to keep their positions, and the department will fill other vacancies “in rank order from the competitive roster.” 

Creating a Unified Department
The department’s greatest challenge now is to cross-train its single-role EMS providers and firefighters without current EMT credentials and integrate them into a unified 2,042-employee “all-hazards” department.

In 2006, DCFEMS had 250 single-role EMS providers, but that number had declined to 207 by October 2008. “A significant population of single-role personnel have taken the opportunity for a lateral transfer within the past two years,” Sa’adah says. 

As of Oct. 15, the department had 184 paramedics (109 single-role and 75 dual-role) and 48 EMT-intermediates (15 single-role and 33 dual-role). “The paramedics and EMT-Is have identical scopes of practice but we’re firmly committed to upgrading all our EMT-Is to paramedics well in advance of the [implementation of] new national provider levels,” he says.  

DCFEMS fields 20 BLS and 17 ALS ambulances, and 19 of its 33 engine companies have ALS providers. Single-role EMS personnel ride only on ambulances, dual-role ALS providers respond only on fire trucks, and dual-role EMTs now rotate onto ambulances for 90-day shifts “to keep their skills up,” Rubin says.

“They not only rotate on and off the ambulance and trucks, but someone may jump from a truck to an ambulance and back during the course of a shift,” Sa’adah adds. “If a patient requires ALS care, a paramedic may jump from the truck to an ambulance, and an EMT on the ambulance would change places with the firefighter on the truck.”

Cross-training of the department’s single-role EMS personnel as firefighters was scheduled to begin in October 2008, but is on hold pending passage of enabling legislation that would allow us to offer new switchover benefits,” Sa’adah said Nov. 1. 

Current single-role EMS personnel will be offered several options. “No one will be required to complete firefighter recruit training,” he says. Those who cross-train should receive a “significant” pay increase as they integrate into dual-role positions and are sworn in as firefighters, and single-role paramedics who are supervisors will retain those positions after they cross-train.   EMTs and paramedics who choose not to cross-train as firefighters will be moved into the equivalent position on the firefighter pay scale.

Those who choose to remain single-role EMS providers will receive at least two weeks of orientation on how to operate safely in an all-hazards department, learning more about the department’s incident command system and the handling of hazardous materials. 

DCFEMS firefighters don’t have an option: They must become EMTs or paramedics. Since 1987, DCFEMS has hired only firefighters who are also EMTs but still had 109 without that credential on Oct. 1. 

A tale of two unions
Two unions currently represent DCFEMS employees: American Federation of Government Employees Local 3721 represents single-role EMTs and paramedics, and International Association of Fire Fighters Local 36 represents fire-suppression and dual-role personnel. 

Local 36, which gains members as single-role EMS providers cross-train, has supported the transition plan. President Lt. Daniel Dugan, EMT, says, “I believe we’re now delivering EMS care better than we’ve ever delivered it in the past.”

But Local 3721 President Kenneth Lyons, EMT-P, says, “I see an agency that is more dysfunctional one year after issuance of the recommendations. The recommendations were to make it more medically centered, but instead of having a fire department that understands an EMS perspective, we have a fire department trying to run EMS as a fire department.”

Lyons says DCFEMS “is getting rid of the EMS medical professionals who are civilians—who came on to do what the agency does 85% of the time: EMS—by offering them better pay and benefits and by attrition.” Very few civilian EMTs and paramedics, he says, “have chosen to go to the fire side and those went for better pay and benefits.”

The EMS Task Force recommended: “All employees shall have the same basic pay and benefits,” and directed the city to develop a plan “to transition to pay and benefits parity between current single-role medical providers and dual-role providers.”

The city released its plan in May, but Lyons faults its definition of “parity” because it offers 4–12% increases to single-role EMS providers who become dual-role, thereby “punishing” those who chose to continue as single-role providers. “Anything less than parity is not parity,” he says.

Sa’adah says the difference in base pay is misleading because firefighters must work 53 hours in a week before overtime pay kicks in, but single-role EMTs and paramedics receive “time and a half” after 40 hours.

In mid-2008, DCFEMS employed the Maryland Fire & Rescue Institute (MFRI) to perform a “baseline assessment” of the skills of all DCFEMS ALS personnel and to provide remedial training to those failing to demonstrate competency. Sa’adah declined to say how many paramedics and EMT-Is received this remedial training. Local 3721 opposed the MFRI test, Lyons says, “because it wasn’t a validated test written by medical professionals.”

Local 3721 has also filed a grievance over the DCFEMS plan to require all its EMTs and paramedics to pass National Registry of EMT exams because personnel must pay for the tests themselves.

Dugan’s greatest complaint is that the department has far too few paramedics, forcing ALS providers on engine companies to handle too many patients during each 24-hour shift. (Most DCFEMS single-role EMS providers work 12-hour shifts.) 

In attempts to hire 100 new firefighter/paramedics, DCFEMS is recruiting nationwide and offering a $7,000 signing bonus. Dugan says, “They haven’t offered a paramedic class for two years to the people already here, although I have 1,700 guys and plenty of them are willing to take a class and provide paramedic care.” But Sa’adah says the department is working on a request for proposals to find a university to help DCFEMS “get our internal paramedic training up and running.” 

“We’ve got some good bones as the skeleton for the EMS system,” Dugan says. “Now we just need more paramedics on the street and equality between our members and Kenny Lyons’ members.”

Other Recommendations
DCFEMS has also undertaken numerous other changes in response to the EMS Task Force recommendations.

To help reduce misuse of EMS resources and improve response times, DCFEMS launched a new “Street Calls Program” last March to proactively address the needs of high-volume 9-1-1 users. (Visit www.jems.com for a story on that program.)

DCFEMS now stations an EMS supervisor in the dispatch center around the clock to work as an emergency liaison officer (ELO), coordinating the distribution of patients to more than a dozen area hospitals and providing clinical and operational support and guidance.

The ELO functions like “a traffic controller,” Rubin says, “to ensure we distribute patients in such a way that we don’t overburden any [emergency department] and we send the patient to the most appropriate hospital.”

According to Sa’adah, a working group with representatives from DCFEMS and area hospitals developed a new turnaround policy that now “starts the clock when our provider hits the [hospital’s] threshold, and the hospital has 25 minutes to do triage and take over custody of the patient. If the hospital hasn’t done that in 25 minutes, the patient can be moved to the waiting room.”

Augustine reports that DCFEMS is also working with the city’s department of health to help cut transports from nursing homes and homeless shelters. For example, he explains, visiting nurses can replace catheters and testing services can provide urine tests and X-rays instead of having EMS transport nursing-home patients to hospitals for those services, and stationing a physician or nurse at a shelter at certain times can cut many low-acuity transports. “EMS is taking an active part in this, but EMS providers won’t perform these services,” he says.

Augustine is especially excited by the department’s implementation of new technology, including mobile data terminals, electronic patient care reports (ePCRs) and Live MoveUPModule (LiveMUM) software that tracks EMS activity in real time and recommends optimum deployment moves.

“Our units respond from fixed locations, but we use Deccan’s LiveMUM to transfer resources as necessary throughout the day,” Sa’adah says. 

Augustine notes that the department has made its chief of IT (information technology) “responsible to the chief of operations” instead of to support services. “That’s a step generally undertaken only by the highest functioning organizations,” he says.

According to Augustine, the department hasn’t yet fully developed its new quality improvement program “because it’s wrapped into development of our new electronic data system.” Currently, he says, 70% of DCFEMS documentation occurs via ePCRs. 

Response Times
In the spirit of transparency, DCFEMS regularly posts response-time data on its Web site. Despite the new programs and efforts, DCFEMS response times did not improve between October 2007 and July 2008 (in fact, they declined slightly). However, the call volume has risen significantly during that time. Moreover, the number of non-critical calls declined from 5,973 in July 2007 to 5,885 in July 2008, whereas the number of critical calls rose from 5,438 in July 2007 to 6,475 in July 2008.

In addition, Sa’adah stresses that the department is “attempting to reduce response-time variance from neighborhood to neighborhood”—a far more demanding task.

“We measure our response times citywide and by every neighborhood,” he says, “and we’re trying to get that information out to the public.”

Stay Tuned
After reviewing the city’s progress on implementing the EMS Task Force recommendations, the Rosenbaum family dismissed its suit in February 2008. But DCFEMS didn’t stop the work to implement those recommendations.

“We’re in uncharted territory doing such sweeping changes in such a short period of time; we’re learning new things every day,” Sa’adah says. “Some things don’t progress as quickly as we’d like, but we’ve made tremendous changes. I think this agency will set the pace for the rest of the country.”