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CONSULTANT REPORT
Monroe County EMS – Monroe County, NY
Comprehensive Emergency Medical Services Study
Table of Contents
METHODOLOGY _______________________________________________________________________________ 8
AREA OVERVIEW_______________________________________________________________________________ 9
The existing EMS delivery model is composed of a diverse mixture of dedicated personnel and
organizations, rich with impressive histories of community service. Many have roots extending back to
volunteer groups of citizens reaching out to help other citizens. Those organizations grew into today’s
multitude of agencies, which are comprised of career and volunteer EMS providers offering varying
levels of service delivery and business sophistication.
The Consultant interviewed system participants and stakeholders, gathered and analyzed data and
developed deployment plans, along with three options for the future of Monroe County EMS. Below is a
summary of the Consultant’s findings.
FINDINGS
Governance of EMS in Monroe County Is Very Weak
There is a complex network of governing bodies where EMS physicians, agency leaders, and others
collaborate to write policy hampered by the absence of reliable and verifiable data describing the
performance of the Monroe County 911 Emergency Communications Department (911 Dispatch Center)
or the performance of the individual ambulance agencies. Implementation of these policies is another
matter. Mechanisms to monitor compliance, by-and-large, are not available to Monroe County. In
addition, the County EMS Office has no statutory authority over much of the activities of local EMS
agencies.
Total response time is the interval from when a call rings-in to County 911 to when a unit is on-site at
the patient. Monroe Ambulance Service does not report response times back to the County 911
Dispatch Center. Rural-Metro Ambulance Service has its own contract objectives and reports and is held
accountable to those times. Chili, Point Pleasant, and Rush respond faster than their target response
times based on nationally accepted standards. Irondequoit, Hamlin, and Spencerport are slower than
these targets by less than 60 seconds. All of the other agencies are slower than these targets by multiple
minutes.
Agency processing time is the interval from when a County 911 request for service rings-in to the local
agency to when the local agency acknowledges its acceptance of the request back to County and notifies
its unit of the request. Agency processing time is a major contributor to slow total response times of
many ambulance agencies.
The County EMS Office should establish a consistent standard level of care (at a minimum Certified First
Responder (CFR) with defibrillation) to be provided by all fire service first response organizations. The
County EMS Office should authorize an Emergency Medical Technician (EMT) level of care, provided that
the fire service organization moves to that level as an agency such that all calls from that point forward
include at least one EMT with the first response contingent. The costs of these additional responsibilities
of the first responders should remain the burden of the local communities, as they are today.
As a matter of imminent public safety, the County EMS Office should establish a medically-mediated
response matrix that authorizes the use of “hot” response only to EMS calls involving substantial risk to
life (ECHO and DELTA), as defined by the Medical Priority Dispatch System (MPDS). All calls classified at
the MPDS levels ALPHA and BRAVO should use only “cold” response, if first response is dispatched at all.
Pending replacement of the antiquated Northrop Grumman Computer-Aided Dispatch (CAD) system,
implement an add-on that provides real time and reliable reports of the on-line/off-line status of
ambulance vehicles and crews (units) among the various ambulance agencies in the County. County
Dispatch may be able to work around some of the deleterious effects of hard boundaries when timely
reports of on-line/off-line status are available. Realistically, this implementation will need to have some
incentive to reward the district ambulance agencies for entering accurate reports of their on-line/off-
line status.
Each agency’s district should be divided into incident zones based solely on call densities and not on
population densities. These incident zones should be designated as “Urban”, “Rural”, and “Remote”
using the criteria presented in the Optimized M-xR Model System. Target response times in each type of
incident zone should be established by the County EMS Office, preferably conforming to nationally
accepted standards.
After operating the new CAD system for six months, and quarterly thereafter, the performance of
Monroe County Dispatch and of each ambulance agency should be verified independently and
documented by the Monroe County EMS Office. Each agency should receive three separate scores — for
response time in its “Urban,” “Rural,” and “Remote” Incident Zones. Providing three scores per agency is
necessary to fairly assess performance between agencies operating in districts with different mixes of
Incident Zones.
Empower the County EMS Office with local legislation to promote compliance of all EMS agencies with
these target response times. Such an approach emphasizes the importance of the timely delivery of
emergency services to the patient, leaves the implementation to the discretion of each ambulance
agency and its local community, and recognizes that there can be as many ways to achieve the target
response times as there are local ambulance agencies.
Regularly publish and publicize the various operational and clinical performance metrics with the goal of
making the district’s ambulance agencies, as well as the general public, aware of the relative
performance of all agencies. Use these performance statistics as leverage to lobby state government to
remove the statues that entrench hard boundaries.
The impact of slow response times in Monroe County on patient outcomes needs to be measured,
especially in the case of life threatening calls. Regularly publish, in cooperation with the medical
directors of the existing ambulance services, clinical performance metrics per Utstein Style for cardiac
arrest reporting guidelines and the Eagle’s Cardiac Risk Assessment benchmark standards.
Empower the County EMS Office with local legislation to promote compliance of all EMS agencies with a
policy that a complete patient care report be provided to the Emergency Department (ED) prior to
departure, unless there is an extraordinary situation (disaster declaration, etc.). Look into the liability
issues surrounding the current practice of providing only abbreviated drop sheets to seek further
leverage to encourage compliance. Seek to establish community awareness of the importance of patient
care records.
Empower the County EMS Office with local legislation to mandate a centralized, uniform system of
electronic patient care records (ePCRs). Alternately, the County should require all agencies to participate
in the Regional Health Information Organization (RHIO) data repository for purposes of analysis and
Work with RHIO and others to develop and implement bidirectional data exchange that uploads ePCR
data directly in to the physician electronic medical record (eMR), and provides ED/hospital discharge
outcomes data directly back to the ePCR data base.
Install an Automated Vehicle Location/Global Position System (AVL/GPS) on all ambulances. Again,
County Dispatch may be able to work around some of the deleterious effects of hard boundaries when
the physical locations of ambulances are available to County dispatchers in real time.
Further develop an incident command capability, such as the National Incident Management System
(NIMS)/Incident Command System (ICS), responsible for major incident planning and management.
More immediately, the County EMS Medical Director should be authorized to take operational control
of EMS actions at emergency scenes.
Retain the existing ambulance service agencies. Have the existing ambulance service agencies contribute
ambulances and crews (units) to County 911 on a per shift basis. Coordinate on-line/off-line status by
time of day across all agencies to match active resources with demand, and thereby relieve operational
pressure on all agencies. This will be especially helpful to the smaller agencies. Implement dynamic
deployment of units. Site the units at the optimum locations identified in this report’s analyses of
historical call densities. Have County 911 dispatch units from these locations.
Centralize billing at the County level and have the County disburse reimbursement payments to the
ambulance agencies. Cost normalization based on out-of-jurisdiction call activity needs to be provided.
Centralize purchasing at the County level.
An intuitive expectation for the success of this approach is supported by two facts. First, such an
approach is already successful with the current contractor, Rural/Metro, operating within the City of
Rochester. Second is the realization that much of Monroe County experiences an “Urban” density of
calls, implying that the experience within Rochester likely applies to Monroe County.
A quantitative expectation for the success of this approach is provided by models of costs and revenues
that show a “revenue neutral” outcome for Monroe County. These models are grounded in this report’s
analyses of historic call densities.
Many of the existing ambulance vehicles may be acquired by, or partner with, the new service agency.
Many of the existing volunteer positions could convert to paid positions. Costs to the County are
expected to be very small. Costs to the municipalities are expected to be very small. The new contractor
may be required to reimburse the County for certain services.
The Consultant reviewed a two-year data extraction from the 911 County CAD system and the same two
years from Monroe Ambulance Service CAD. The County is operating with an old version of a Northrop
Grumman CAD written in Cobol. Data can be extracted only as a comma delimited flat file. The extracted
data file had many problems, including multiple duplicate entries, significant outliers and corrupted data
fields.
Ten percent (40,000 of the more than 400,000 calls) were discarded because the data was suspected to
be erroneous. Data that exceeded the following limits were assumed to be “data errors” rather than
actual events and were excluded from the Consultants’ analyses:
1. Dispatch Time greater than 10 minutes
2. Chute Time greater than 1 hour
3. Response Time greater than 1 hour
The Consultant further used the Monroe Ambulance data set in order to normalize the 911 Dispatch
Center data. Monroe Ambulance call volume set was considered as the accurate call volume. The 911
Dispatch Center data set was corrected to those values, thus eliminating duplicate calls in the data set.
Using the corrected/amended data set, the consultants plotted call density across the County and
developed a series of deployment models. The modeling efforts formed the basis of findings and options
presented in the report.
Financial data provided to the Consultant was scant, at best. Conclusions based on information available
in Fitch proprietary databases and on experience with like systems, were made.
Monroe County is the center of the seven-county Rochester region, accounting for 64% of the region’s
population, yet the Monroe County's population has grown by just 1% since 2000. Monroe had around
744,300 residents in 2010, with about 28% of those residents living in the City of Rochester and 72%
living in the County, ex-Rochester. The population of the County, excluding Rochester, is 2.6 times larger
than that of the City of Rochester.
Monroe is the most racially and ethnically diverse county in the area, and home to most of the region's
cultural and tourist attractions. Its economy and population counts are largely stagnant. More
significantly, the City of Rochester lost about 4% of its population between 2000 and 2010, compared to
a 2% increase in the state and a 10% increase nationwide in the past 10 years.
Monroe County's population has been aging. The number of adults 40 to 59 years old increased by 7%
from 2000 to 2010, making it the largest segment of the population and consistent with regional, state
and national trends. During that same period the number of 60 to 84-year old residents increased by
18%. The largest proportional increase was in the number of senior residents 85 and older, which grew
28%. Although this group represented only 2% of the total county population, the increase in both older
groups highlights the growing need for sufficient elder care and support services. The table below is a
snapshot from County planning documents depicting basic demographics for the County, Rochester and
the Towns and Villages in Monroe County.
The highest population densities are in the City of Rochester and East Rochester. Brighton, Greece, and
Irondequoit represent a second tier of population densities. Clarkson, Hamlin, Mendon, Rush, and
Wheatland represent the sparsest population densities.
1 Monroe County Total Population and Population Change 2000-2010. Thomas Goodwin, Planning Manager, Monroe County.
http://www2.monroecounty.gov/planning-planning.php
Monroe saw a decline (-13%) in its overall mortality rate and much larger reductions in mortality from
certain diseases. From 2000 to 2008, Monroe residents had declines in mortality from heart disease
(-22%), cancer (-4%), respiratory disease (-10%), and stroke (-33%). 2
According to the New York State Department of Health, Monroe County has seven main hospitals as
reflected in the table below. Significantly, five of these are within the City of Rochester with only two of
them in more peripheral locations. 3
As of September 2012, the New York State Department of Health listed 29 ambulance services as being
licensed in Monroe County. In conversations with the County EMS Office, five of the agencies are no
longer providing transport services and two are to be added to the list resulting in a total of 26
ambulance (transporting) agencies in Monroe County. The amended list is in the table below.
2
ACT Rochester, “Community Indicators for the Greater Rochester Area”. ACT Rochester is a partnership of Rochester Area
Community Foundation and United Way of Greater Rochester. http://www.actrochester.org/OurCommunity/Monroe/.
3
New York State, Department of Health, Bureau of EMS, EMS Agency and Hospital Information By County.
http://www.health.ny.gov/professionals/ems/counties/monroe.htm. Information supplement by County EMS Office.
Of these ambulance services, Rural/Metro Medical Services and Monroe Ambulance are the largest
providers. Significantly, both are private for-profit agencies operating with paid staff. At the other end of
the spectrum are agencies such as Hamlin and Rush. These are located in small municipalities with low
population densities, and operate on a not-for-profit basis using volunteer staffing.
Twenty-eight fire first responder agencies support Monroe County’s EMS system. They vary in size and
capability from the large metropolitan City of Rochester Fire Department to smaller all-volunteer
departments outside the City. A number of Monroe County fire agencies have transport capability and
are included in the transport agencies listed above. The table below provides a list of fire first response
fire agencies that do not have transport capability.
Between 2000 and 2010, the population of Monroe County increased by 1.2%. Over the same time span,
the population of the City of Rochester decreased by 4.2%. Population growth in the County, ex-
Rochester, was greater than the loss of population experienced by the City of Rochester. The hotbeds of
population growth in the County are the towns of Henrietta, Pittsford, and Webster.
4
Table prepared by Monroe County Department of Planning and Development. Source: US Census Bureau, 2010 Census
Redistricting Data (PL 94-171), released March 24, 2011.
The most striking aspect of this projection is that the total population of Monroe County will be
numerically stagnant over the near future.
PAD also analyzed the internal dynamics of this projected population. While the total population may be
stagnant, the distribution of ages within this population is changing dramatically. For purposes of the
delivery of healthcare and emergency medical services, the most significant cohort of ages is the
segment 65 years and older. Changes in the number of people in this age bracket are presented in the
figure below.
5
Cornell Program on Applied Demographics. http://pad.human.cornell,edu/counties/projections.cfm
Significantly, the population in the 65+ age group will increase 24% between 2010 and 2020. Between
2010 and 2030 it will increase by 35%.
First, the Department of Emergency Medicine, University of North Carolina at Chapel Hill, Chapel Hill,
North Carolina, conducted a retrospective study of 2,743,221 EMS transports to emergency department
across North Carolina in 2007. A major finding of this study was that individuals 65 years of age or older
accounted for 38.3% of all EMS transports to North Carolina emergency departments. 6
6
TF Platt-Mills, B Leacock, JG Cabañas, FS Shofer, SA McLean, Prehospital Emergency Care, 2010 Jul-Sep; 14(3): 329-333. doi:
10.3109/10903127.2010.481759.“Emergency medical services use by the elderly: analysis of a statewide database.”
www.ncbi.nlm.nih.gov/pubmed/20507220.
Figure 4. EMS Transports by Age Group Jul 2000 – Jun 2001 Pinellas County, FL
What is more relevant to predictions for Monroe County, are the statistics reported for the summer
months in Pinellas County. Per the 2000 United States Census, Pinellas County had 22% of its domiciled
population in the 65+ age group. During the summer months, at least 50% of all EMS transports involved
the 65+ age group. One fifth of the domiciled population accounted for one half of the EMS transports.
Similar observations regarding age and EMS transports were made in smaller and earlier studies in
Forsyth County, North Carolina in 1995 and in Dallas, Texas in 1990. 8
The consequences of these observations for Monroe County are clear. Even through total population
will be stagnant, the demand for EMS transports will grow by about 10% between 2010 and 2020
because of the aging population. A growth rate of 1% per year in transports appears modest and should
not apply extraordinary additional pressure to the County’s emergency medical services, assuming that
the growth is distributed uniformly across the County. However, assuming a uniformly distributed
growth of the population in the 65+ age bracket is optimistic. The existing demographic data for
Henrietta, Pittsford, and Webster already show a very asymmetric growth of population in the County
and these areas will be impacted more significantly.
7
D Haynes, “The Impact of Snowbirds to Pinellas County Emergency Medical Services”, Oct., 2003.
psrdc.fmhi.usf.edu/Pinellas/TheImpactofSnowbirdstoPinellasCountyEMS.pdf
8
JL Wofford, WP Morgan, MD Heuser, E Schwartz, R Velez, MB Mittelmark, Am J Emerg Med, 1995 May, 13(3): 297 - 300.
“Emergency medical transport of the elderly: a population-based study” and CE McConnel, RW Wilson, Soc Sci Med, 1998 Apr,
46(8): 1027 - 1031.“The demand for prehospital emergency services in an aging society”.
The 911 public safety access point (PSAP), also known as the Emergency Communications Department
(ECD) is an agency of the City of Rochester that provides service throughout Monroe County. The County
and the City have a renewable 10-year contract under which the County provides all radio, telephone
and computer equipment while the City provides and maintains the building in which the PSAP is
located. ECD, or the County 911 Dispatch Center, as it is referred to in this report, provides dispatching
services for all fire departments and EMS agencies in the County. The two for-profit EMS agencies,
Monroe Ambulance and Rural/Metro Corporation, maintain sophisticated dispatch systems and
dispatch their own units after an emergency call is transferred to them from the County 911 Dispatch
Center.
Monroe Ambulance is a family-owned, for-profit corporation that has operated in Monroe County since
1975. The company holds a countywide Certificate of Need and competes with Rural/Metro in the non-
emergency patient transport market within the City of Rochester and the greater County. The company
provides backup services under mutual aid agreements with a number of the suburban EMS agencies
and is available to back-up Rural/Metro as needed.
Monroe Ambulance operates a sophisticated dispatch system and can receive 911 calls directly from the
911 Dispatch Center. The company is active in the community and has grown exponentially over its 30+
years of operations.
The City of Rochester currently contracts with Rural/Metro Corporation to provide paramedic treatment
and transport. Rural/Metro, a private-for-profit transport agency owned by a private equity firm, has
held the contract with the City since the mid-90s. Rural/Metro transports both emergency patients
(under exclusive contract) and non-emergency patients (non-exclusive rights) with paramedic advanced
life support (ALS)-staffed and equipped ambulances, as appropriate. Rural/Metro operates under a
performance-based contract with the City to respond to emergency 911 calls.
The current contract was the result of a competitive procurement process. The contract took effect on
April 1, 2012. The City receives emergency response services at no cost to taxpayers (no subsidy) and, as
part of the contract the company is obligated to reimburse the City for fire department first response
Services provided under contract include: advanced and basic life support services, critical care
transport, specialized care for bariatric patients and non-emergency ambulance service to hospital
systems and healthcare facilities throughout the area.
Both Monroe Ambulance and Rural/Metro deploy ambulances in a dynamic manner, and staff
ambulances to meet call demand based on historical call data. Both agencies hold countywide
certificates of need in Monroe County.
The contract between Rural/Metro and the City of Rochester spells out the following response time
performance requirements within four City-designated zones as follows:
Response time is measured upon transfer of a call from the County 911 Dispatch Center and receipt of
the call at Rural/Metro Dispatch Center. The majority of the City of Rochester is an “Urban” designated
area, based on the density of calls. The City’s performance requirements for Rural/Metro are within
accepted standards for emergency medical responses.
On November 29, 2010, Dr. Jeremy Cushman, the County/Regional Medical Director issued Advisory 10-
18 outlining Regional Performance Measures for Urban/Suburban and Rural areas that are summarized
in Tables 8 and 9. Dr. Cushman notes in the advisory memorandum that the performance measures are
endorsed by the Monroe-Livingston EMS Council, the Monroe-Livingston REMAC, the Livingston County
Board of Health, and the Monroe County EMS Advisory Board.
The Advisory memo indicates that the Urban/Suburban and Rural designations are based on population
density. Later sections of this report discuss in depth the errors incurred by using population density as
the basis for performance designation. Briefly, 72% of the population lives outside the City of Rochester,
yet at least 48% of calls occur within the City. Using population density could result in areas being
designated as Rural, which based on call density (need), should be deemed Urban/Suburban.
Despite the fact that Monroe County has no statutory authority over much of the activities of EMS
agencies (first responder and ambulance services alike), there is a network of governing bodies where
EMS physicians, agency leaders, and others collaborate in an effort to make policy and resolve
differences. Monroe County, through its EMS Coordinator and Medical Director, actively participates in,
and in many cases provides active leadership to, the activities of each group.
The EMS Office has been active, aggressive and enthusiastic about improving the County EMS system
and the role of EMS agencies in improving the health and safety of the community. Examples of current
EMS Office functions include:
§ Providing technical and administrative support to local emergency medical services agencies
§ Investigating and develops recommendations dealing with problems impacting the EMS system
§ Administering training programs and services for EMS agencies
§ Providing on-site medical control and quality assurance through the Monroe County EMS
Physician Response Vehicle
§ Administering EMS Mutual Aid plan
§ Serving as information resource to governmental and local agencies (including hospitals and
ambulance services) regarding EMS
§ Providing support to Monroe/Livingston REMAC, EMS Council and EMS Advisory Board
§ Administering County supported Critical Incident Stress Management Program
§ Responding to major incidents including Hazardous Materials
§ Staffing the EMS desk at the County Emergency Operations Center (EOC)
Prior to the EMS office putting this contract in place, many fire and EMS agencies did not have a medical
director as required by NYS regulations. Since this contract has been put in place, all regulations are met,
such as real time field auditing by the physician, support for special operations etc. The EMS portion of
federal grants has funded equipment and supplies for the Medical Director.
The Medical Director’s overarching objective is to establish medical policy for prehospital care and
operations of Emergency medical Services in the County. He provides medical direction and oversight
for a number of system participants and programs including but not limited to:
§ The County’s Public Access Defibrillation Program for all Automated External Defibrillators
(AEDs) owned/maintained by the County
§ Medical review of patient outcomes and statistical data a necessary to protocol application and
modification
§ Advice to the Monroe County Public Health Department on all matters relating to emergency
medical providers and issues as they may arise in relation to their impact on public health
The Medical Director helps all special teams to meet or exceed Federal Emergency Management Agency
(FEMA) medical Equipment/Service Capability targets at specialized levels. Special teams include the
Monroe County Hazardous Materials Team, Sherriff’s Department Tactical Team and specific regional
initiatives such as the Urban Search and Rescue and Regional Incident Management Team. Routine
dispatches of the Medical Director are to mass casualty incidents, when there are three or more
ambulances on a scene, GRIA Alert 1, 2 or 3, Hazmat calls, working fires and special operations incidents.
As detailed in the Medical Director’s job description, he is to set and ensure compliance with patient
care standards including communications standards and dispatch and medical protocols, and oversee
the coordination of activities such as mutual aid, training, disaster planning and management, hazardous
materials response including weapons of mass destruction and terrorism.
EMS AGENCIES
The level of care provided by ambulance service agencies operating in Monroe County breaks down as
follows:
§ 11 ambulance agencies provide paramedic or advanced life support (ALS) care,
§ 15 provide basic life support (BLS)
In order to gain a better understanding of the ambulance service agencies, the Consultant sent a survey
to the 29 agencies listed by DOH, augmented by additional agencies per the EMS Coordinator and those
that may provide mutual aid response into Monroe County. In total, the survey was sent to 42 agencies
and administrative personnel. Only responses from the agencies were considered. Of the total, 20
agencies responded and substantially completed the questions.
The survey included 29 questions about demographics, fleet size, calls, responses and transport volume,
volunteer and paid personnel, personnel certifications, subsidies received, organizational structure,
transport billing, special response capabilities and identification of major issues.
A list of the agencies that received the survey, along with notations of those that completed it and those
that did not is provided in Attachment A.
Agencies were asked to self-assess in six specific areas. It is notable that of the 20 that answered, 13
answered that they are at acceptable level with regard to personnel and finances. There is no clear
pattern in the other areas of the self-assessment.
The following table provides detailed information on volunteer versus paid staff, medical certifications
of paid and volunteer personnel and the number of licensed ambulances and quick response vehicles
(QRVs) available.
9
This is the self-assessment information provided by Greece in the survey; however, Greece is a paramedic-level agency.
A surprising six agencies report that all field personnel, including the Chief Officer, are volunteers. Five
of the agencies report all paid EMS personnel and a paid Chief Officer position. The remaining nine
agencies are some combination of paid and volunteer personnel. “Combination” for EMS personnel
means that both paid and volunteer personnel staff ambulances. It is typical for combination agencies to
staff with paid personnel during weekday work hours and to augment with volunteer staffing in
evenings and weekends.
It is important to note that the number of EMTs and paramedics is likely to be duplicative. Many paid
personnel work and volunteer with more than one agency. Nevertheless, according to the 20 survey
respondents, there are 575 paid EMTs and 333 paid paramedics. The 20 agencies report a total of 106-
licensed ambulance vehicles and 36 licensed Quick Response Vehicles.
Swiftwater Rescue
Bariatric Patient
Rapid Sequence
EMS Support to
Agency
Rope Rescue
Dive Rescue
Intubation
Ice Rescue
HAZMAT
Machine
Squad
Brighton
Chili
Churchville Yes Yes Yes
E. Rochester
Greece
Henrietta Yes
Hilton Yes Yes
Honeoye
Monroe Yes Yes Yes Yes Yes Yes Yes Yes Yes
NE Quad ALS Yes
Penfield Yes Yes
Perinton
Rural/Metro Yes Yes Yes Yes Yes Yes Yes Yes
Rush Yes Yes Yes Yes
Scottsville Yes
SE Quad MCCU Yes
Spencerport
U of R MERT
W Webster Yes Yes Yes Yes Yes Yes
Xerox Yes Yes
Total 3 6 1 1 3 3 2 0 4 5 4 2 6
Special capabilities are scattered. Only Rural/Metro and Monroe Ambulance approach the majority of
the 13 capabilities in the survey. The table below provides information about local financial support,
patients transport numbers and other administrative information.
Eleven of the 20 agencies that responded to the survey report receiving a tax subsidy from their local
jurisdiction. Nine report no tax support. In retrospect, an additional question could have been included
asking whether or not there is indirect or in-kind support to the agency. Frequently, local communities
provide building space at no cost or below market rates as well as access to discounted fuel and other
commodities. Some communities prefer to maintain ownership of ambulances or other major assets.
The 20 agencies that responded to the survey report having transported 100,431 patients in CY2011. Of
the 20 agencies, six do not bill for their transport services. Of the 14 that bill for service, 12 contract out
this function.
CON, structure,
service training
Future training
Increased pre-
training issues
cannot afford
management
Mutual aid &
performance
County EMS
Threatened
Inadequate
closest unit
Need more
volunteers
collections
measures
paid staff
Need but
response
Bad debt
takeover
financial
Monroe
Current
process
and/or
issues
costs
Agency
Brighton X
Chili X X X
Churchville X
E. Rochester X X X X
Greece X X X
Henrietta X X X
Hilton X X X X X
Honeoye X X X X
Monroe X X
NE Quad ALS X
Penfield X X
Perinton X X X X
Rural/Metro X
Rush X
Scottsville X X X X X X X X
SE Quad
X X
MCCU
Spencerport X X X X
U of R MERT X X
W Webster X X
Xerox
Total 11 3 3 8 6 7 3 5 3 4 0
Eleven of the 20 survey respondents noted that they need more volunteers. This was the most
significant, but not unexpected, issue reported by the agencies. The next most listed major issue was the
cost of pre-training for field personnel. Costs of training to become certified are likely to be a barrier to
volunteering.
All but three fire agencies are municipal or district-based organizations. Call volumes range from a low of
30 in CY2011 to a high of 4,474.
The chief operating officers for a surprising number of fire agencies are volunteers. Again, the number
EMTs and paramedics in the system may be duplicated, as individual providers tend to work and
volunteer for more than one agency.
Special operations capabilities appear to be diverse among the fire agencies. Most of the agencies
report a concern about insufficient numbers of volunteers and current training issues and costs.
The County Fire Coordinator administers the Monroe County Mutual Aid Fire Plan. This plan, in
existence since 1941, is the basis for mutual aid fire resources and responses for both in and out of
Monroe County for major fires, disasters and hazardous material-related incidents. Monroe’s 12
volunteer deputy fire coordinators assist the Fire Coordinator with field responses and administration of
the Mutual Aid Fire Plan. The Mutual Aid Plan is robust and is highly functional. Importantly, the plan is
unhindered by the type of impacts that the New York State Certificate of Need process has on the
County’s ambulance services.
The Fire Bureau leads a specialized unit of firefighters from all Monroe County fire agencies. These
firefighters comprise the Monroe County Hazardous Materials Response Team. The Hazmat Team has
been in existence since 1984 and continues to respond to hazardous material incidents today. The
Hazmat Team is led by the Assistant Fire Coordinator and a volunteer deputy Hazmat coordinator. This is
a model that, in consultant interviews, was held out as a successful one and a model that could be
emulated by the County to meet the special operations needs in the EMS arena.
In consultant interviews, the fire community identified their top three issues regarding EMS in Monroe
County as follows:
1. The EMS community relies heavily on the fire service for “lifting assistance.” There is a widely
held perception that the EMS agencies do not require their members to meet any standard of
physical fitness, rendering many unable to participate in the lifting and moving of patients.
Spokesmen indicated their belief that the EMS community needs to step up and make sure that
they are able to “carry the load” that is required.
2. Fire services render aid as medical first responders. They believe that they wait too long for
ambulances to arrive, particularly in communities that rely on volunteers to staff ambulances.
This contention is supported by the data derived during the course of this review.
3. Fire services respond to EMS events using an inconsistent matrix regarding use lights and sirens
that must be “remembered” and applied by dispatchers on a district-by-district basis. The fire
service needs to standardize its responses to EMS events.
Despite well-meaning volunteers and agencies, the response of the Monroe County fire service first
responder organizations to requests for medical assistance is erratic, inconsistent, and in some cases
detrimental to the health and safety of the community. Some fire service organizations do not respond
to EMS calls at all. The level of medical care provided varies widely, sometimes involving a single
Certified First Responder and on other occasions involving the response of several emergency medical
technicians (EMTs) and one service provides firefighter paramedics. Some fire service organizations
SYSTEM DATA
This section of the report provides analysis of the data available to the consultants for calendar years
(CY) 2010 and 2011. The overall objective of the analysis is to report on current performance and to
project what system performance in Monroe County could be achieved if an optimized system was
adopted.
The Northrop Grumman Computer Aided Dispatch (CAD) System used by the Monroe County Emergency
Communications Department (911 Dispatch Center) is antiquated and at the end of its service life. The
major deficiency of this system is that it cannot automatically generate retrospective reports detailing
the performance of the system as a whole or the performance of any individual ambulance service
within the system. Prior to the analysis presented in this report, agencies at both the county and local
levels had little concrete data available for comparison and/or to drive their policy decisions regarding
emergency medical services.
Data Deficiencies
The data analyzed in this report was culled from Monroe County 911 Northrop Grumman CAD system.
The consultants obtained raw dispatch records for the CY2010 and CY2011. The Northrop Grumman
CAD’s raw data was output in a partially corrupted format. Fitch applied proprietary algorithms to the
raw records to remove the corrupted records. The Consultant team believes that the corrupted records
occurred randomly and that the removal of the corrupted records from the data set does not introduce
any systematic bias into the remaining records.
The Consultant identified an anomaly in the record creation algorithm used in the Northrop Grumman
CAD software that resulted in duplicate entries for a single call whenever the call was transferred to a
first ambulance service and then bounced to a second ambulance service. The reported number of calls
handled by the system was thereby inflated. The Consultant was able to estimate the duplication
inflation by comparing calls transferred to Monroe Ambulance with the number of calls logged by the
Monroe Ambulance CAD. The Monroe Ambulance CAD is an up-to-date reliable system. The Consultant
chose to compare to Monroe Ambulance’s data instead of Rural/Metro’s data in order to establish a
correction factor because Monroe Ambulance’s call locations are more consistent with those
experienced by all other agencies in the county. The correction factor was applied to the Northrop
Grumman raw data records to best represent the true volume of calls for the county as a whole.
CALL VOLUMES
There is a wide variation in the call volumes of the various EMS agencies in Monroe County. The figure
below indicates the call volumes for 34 agencies for which calls were dispatched from the Monroe
County 911 Dispatch Center during CY2011. Call volumes are amended as described above. Call volumes
for Rural/Metro and Monroe Ambulance are included in text in Figure 5 to avoid a significant scale issue.
The purpose of Figure 5 is to provide a visual sense of the relative number of calls handled by the
various agencies. As explained in the preceding section, “Data Deficiencies,” the absolute number of
calls per agency is under reported.
As noted above, Rural/Metro and Monroe Ambulance respond to 56% of all calls in Monroe County. This
leaves some 30 individual ambulance services attempting to achieve response time performance and
financial sustainability based on potential revenue from the remaining calls. Based on the
adjusted/corrected call volumes, at least 17 Monroe County ambulance agencies respond to fewer than
1,000 calls per year. Calls do not always result in a transport, which further undermines financial
sustainability.
The low call volume makes it difficult for these ambulance services to afford to staff ambulances 24
hours a day, 365 days a year without receiving some form of tax subsidies and/or a heavy reliance on
unpaid volunteers. The use of unpaid volunteers, while cost effective, often comes with the hidden cost
of longer response times to patients. The response time of an ambulance service that relies upon
volunteers is often lengthened while the local dispatcher rousts and assembles a crew for a response.
10
SE Quadrant is an ALS fly-car service (non-transporting) and covers ALS level calls with East Rochester, Penfield, Periton and
Pittsford. SE Quadrant responses appears in the CAD data, which likely results in duplications that could not be sorted out.
The hard boundaries lead to a system that is not patient centric in that it incurs response times to the
patient that are longer than could otherwise be achieved by assigning the closest ambulance, regardless
of district. The policy of hard boundaries limits the system’s ability to do the right thing for the patient.
BUILT-IN INEFFICIENCIES
The Monroe County EMS system is inherently inefficient because the smaller ambulance services act
independently and do not coordinate the number of active units and their levels of staffing in response
to predictable changes in demand.
Performance-based EMS systems look at how call demand changes by day of week and time of day.
Analysis of data over several time periods allows the “system” to staff ambulances to meet the peak
demand and then reduce ambulances when and where calls are not prevalent. The figure below
indicates the day of the week changes for calls in Monroe County for CY2011.
The figure above clearly depicts the dramatic difference in call volume with a sharp minimum number of
calls at 0500 to 0600 hours (8.3 calls/hour) and a broad maximum number of calls occurring at 1100 to
1800 hours (24.6 to 24.7 calls/hour). There is three times the number of calls during this peak period
than at the minimum. Clearly, operating a uniform number of active staffed ambulances throughout the
day, despite the changes in demand, is inefficient.
The most costly factor in providing ambulance services is the crew. Agencies operating in larger and
denser service areas such as the City of Rochester are able to be more efficient as they adjust the
number of staffed units (unit hours) in response to the predictable changes in demand based as noted in
the Figures above. The smaller ambulance agencies scattered across Monroe County do not have this
opportunity. When an agency operates only one or two ambulances, adjustments to the number of
active units becomes an all-or-nothing proposition. When each of the smaller ambulance services acts
strictly independently as they do in the Monroe County system, there is no opportunity to fine-tune the
number of active units among the smaller services by coordinating who goes off-line.
Standards published by the National Emergency Number Association (NENA) are consistent with NFPA
1221 with additional embellishments as noted in the table below.
Chute Time is the time interval from when the district ambulance service receives notification from the
Monroe County 911 Dispatch Center to when the ambulance with its crew is rolling en route to the site
of the emergency. The table below indicates the NFPA standards for Chute Time performance.
The table below is a simplified depiction of the first six of the multiple steps in the flow of a 911 call.
Step 5 in the table is very significant. The dispatcher at the 911 Call Center has authority to assign a unit
Table 21. Initial Steps of 911 Call Handling and Performance Standards
Step Action
1 An individual observes an emergency event and determines the need for emergency intervention.
2 The individual initiates a call to 911.
3 A call taker at the 911 Dispatch Center answers the incoming call, identifies whether it should be
medical, police or fire that handles the call, and transfers the call to a dispatcher.
NFPA 1221 6.4.5 Performance Standard: Less than 30 seconds for 95% of calls
4 The dispatcher answers the transfer and uses experience and/or scripted dialogs based on best practices
to identify the category and acuity of the call.
NFPA 1221 6.4.2 Performance Standard: Less than 15 seconds for 95% of calls
5 The dispatcher identifies an available response unit and “tones out” that unit.
NFPA 1221 6.4.3 Performance Standard: Less than 60 seconds for 95% of calls
6 The unit “turns-out” and begins rolling to the site of the emergency.
NFPA 1710 Performance Standard: Less than 90 seconds for 90% of calls
The complete flow of a 911 call in a typical high performance system is schematically depicted in the
figure below.
This schematic is presented to show the relationships between the named intervals of time in a typical
911 call. This schematic is incomplete with respect to procedures existing in the Monroe County System.
Two additional tasks are introduced between T2 and T3 because the County dispatcher does not have
In many smaller 911 systems, the call taker and the dispatcher may be the same individual. The clinical
data regarding emergency medical response is clear: for calls where time is of the essence, faster
response times correlate to better clinical outcomes. The standards published by NFPA and NENA reflect
this reality and emphasize the need for rapid dispatch to medical emergencies but allow as much time
as possible for responding units to travel to a patient’s side. Dispatch centers that execute Step 3, Step
4, and Step 5 in less than 105 seconds or one minute, and forty-five (1:45) seconds for 95% of calls are
considered “high performance.”
In any large system things invariably go wrong. The County’s 911 Northrop Grumman CAD does not
individually log the time intervals of Step 3, Step 4, and Step 5 described in the table above. The inability
of the Northrop Grumman CAD System to provide concrete data for each of the three steps impedes
attempts to diagnose issues and implement improvements. Too often, the diagnosis of an incident gone
wrong degenerates into conflicting anecdotal recollections that are ultimately irresolvable.
How long the patient has to wait before receiving help is the aggregate of these four time intervals.
Dispatch Time
The table below looks at the dispatch interval component of 911 call handling, as described above, for
30 agencies for which data was available. It depicts the time for the County 911 Dispatch Center to
answer the call, to determine the type and location of the emergency, to assess the acuity of the
emergency, and to dispatch an ambulance.
In the Monroe County system, there are two significantly different dispatch processes that occur. In
both processes, County Dispatch answers the call and then determines its type, location, and acuity. For
The figure below depicts the flow of an EMS call in Monroe County. As noted above, the difference
between dispatches to Rural/Metro and all other agencies is that for Rural/Metro the transfer to the
agency dispatcher and acknowledgement of the accept/decline decision are effectively instantaneous.
The table below presents the dispatch times ( 0:00 -> T3 in Figure 10 above) as logged by the Northrop
Grumman CAD for the County 911 Dispatch Center for life threatening calls at 90% reliability.
The data, as logged, indicates that Monroe County 911 Dispatch Center’s dispatch performance is in all
cases slower than the 1:45 NFPA Standard. Call handling times range from 2:02 for calls to the
Rural/Metro district to 7:31 for calls to the Scottsville district.
In the opinion of Fitch & Associates, the dispatch time reported for calls going to the Rural/Metro
district is the best available indicator of how well County Dispatch is currently performing. The 2:02
dispatch time is a metric based on handling 80,000 calls, or 48% of all EMS calls processed by the County
Dispatch Center. For the remainder of this report, the 2:02 dispatch time will be used as the
“benchmark” representing the intrinsic performance of the County 911 Dispatch Center.
Furthermore, it is the opinion of Fitch & Associates that variations in dispatch times for calls going to
other agencies reflect events occurring locally at that agency and not variations at County Dispatch.
Dispatch times beyond 2:02 are delays that can be attributed to the local agency locating and assigning
an available crew and ambulance before acknowledging acceptance of the request for service back to
County Dispatch. Call processing times for those agencies can be refined by subtracting the 911 Dispatch
Center benchmark time (2:02) from the entries in the table above in order to reflect the time needed by
agencies to locate an available ambulance (labeled Agency Processing Time in the table below).
The table above indicates wide variations in the time for agencies to locate staffed, available
ambulances on 90% of calls to their service area. The agency processing time for Rural/Metro is
assumed to be instantaneous. The agency processing times for Chili, NE Quad, Penfield, and Spencerport
are reasonable, given the delays inherent in system that uses radio calls to communicate and
acknowledge a request for service between County Dispatch and the local agency.
Monroe County has no policy governing the time interval between the request for service ringing-in
from County Dispatch to the local agency, and the local agency acknowledging its accept/decline
decision back to County Dispatch. In the opinion of Fitch & Associates, it is unreasonable for any agency
to take three, four and five minutes to make the accept/decline decision and acknowledge it back to
County Dispatch. Given the existence of modern communications and wireless data links, the local
dispatcher should be held accountable for knowing the status of all the agency’s units at all times and be
able to answer the accept/decline question without delay. The accept/decline decision should be
reached in a matter of seconds and not multiple minutes.
Chute Time
In the Monroe County system, chute time is the interval from when the dispatcher at the local
ambulance agency notifies an ambulance and its crew of a request for service to when the unit is rolling
en route to the site of the emergency. Fitch decided not to attempt an analysis of chute time because
the demarcation between agency response time and chute time is especially blurry.
What is a “reasonable” interval and at what point in the “MAYBE” process does the local dispatcher
commit back to County Dispatch. There are as many answers to these questions as there are agencies.
Some unknowable portion of the chute time is certainly embedded in the agency processing time.
Knowing this portion would not change the conclusions of this report.
En Route Time
En route time is the time interval from when an ambulance begins rolling from its base to when it arrives
at the site of the emergency. En route times are, of course, impacted by time of day and day of week
(rush hour on a week day versus the same time on a weekend), by the road networks, geographic
impediments and severe weather events that confront ambulances. More importantly, the en route
time interval reflects whether the ambulance was based in the right location compared to historical call
demand. En route times can only be improved by choosing the optimum locations to station ambulances
waiting on standby; driving faster does not change en route time significantly. An agency can attempt to
understand and improve performance only by looking at historical data, noting significant events (such
as a major storm or roadway blockages due to construction) and looking at station locations.
The Monroe-Livingston Regional EMS Council (MLREMS), with the endorsement of the Monroe-
Livingston REMAC, the Livingston County Board of Health and the Monroe County EMS Advisory Board
adopted the following regional Performance Measures in the MLREMS November 29, 2010 Advisory 10-
18: Regional Performance Measures. The table below addresses Advisory Memo response time
performance for Urban/Suburban designated areas and the next table addresses Advisory Memo
response time performance for Rural designated areas.
The performance measures above reflect the consensus of most EMS systems in the US and Canada. 11
However, the Advisory memo notes that the Urban/Suburban and Rural designations are based on
population density as opposed to call density. Best practice is to use call density as the indicator for
application of an Urban or Rural performance measures to a particular district.
The County Medical Director reports that Urban/Suburban and Rural response zones have not yet been
defined. The system is operating without agency specific guidelines for response times to patients. The
consultants recommend that if and when the system undertakes to monitor response time
performance, that it be measured against incident zones as determined by the call density formulas
presented in this report.
Underscoring the importance of the Urban or Rural designation is the unexpected and surprising finding
of this report that the majority of Monroe County qualifies as “Urban” when applying the standard
definition based on call densities of two calls per square kilometer per month. The Consultant learned
through the interviews that many, if not most, of the Monroe County system participants believe that
much of the greater County is “Rural” for application of response time standards. Apparently, local
perceptions lag actual demographics.
11
Dr. Joseph Fitch, JEMS, June 25 2007, “Response Times: Myths, Measurement and Management.”
http://www.jems.com/article/communications-dispatch/response-times-myths44-measure
Several ambulance agencies do not report back to County Dispatch when their units begin rolling en
route. Monroe Ambulance does not report back to County Dispatch when their units arrive on-site.
Consequently, the entries in the table above are incomplete.
Ambulance agencies in Monroe County are not required meet the standards for response times
proposed by the County Medical Director. While the MLREMS advisory prescribes standards are
somewhat in line with best practices, the exclusion of the dispatch time from total response time
significantly misrepresents what a patient actually experiences. Rural/Metro is a special case because it
operates under a contract that specifies metrics of performance
To further interpret the data presented in the table above it is necessary to introduce the concept of
composite response times applicable to each agency’s district. We emphasize that the use of a
composite response time is a stopgap intended for this report only. Fitch & Associates recommends
that after the new CAD is installed, each agency should receive three separate scores based on its
response in the urban, rural, and remote incident zones comprising its district. Incident zones are to be
defined based on call densities as described in “Defining Incident Zones” as discussed in the Optimized
M-xR Model System.
Reporting three response times per district is not possible at this time because the detailed data is not
yet available. What is available at this time is the percentage composition of urban, rural, and remote
incident zones comprising each agency’s district as presented in the figure below. The figure below is in
this position for convenience of the reader. It is based on the analysis of data described in “Defining
Incident Zones” below and displayed in that section.
Fitch then derived a composite target response time for each agency based on the distribution of calls
occurring in the urban, rural, and remote incident zones present in each agency’s district.
The first step was to apportion urban:rural:remote calls per incident zone in the ratio of 64:8:1; to assign
a target response time to each call based on the type of zone it occurs in; to sum the target response
times over the district; to sum the number of calls over the district; and to divide the summed response
times by the summed number of calls to obtain a “composite” target response time per call.
The percentage of urban, rural, and remote incident zones and composite target response times for
each agency’s district are presented in the table below.
The composite target response time is a single parameter that represents a response time for the
district as a whole and accounts for response times on calls in the urban, rural, and remote incident
zones (the subzones) comprising the agency’s district. The target response times in the subzones used in
this calculation are: 8:59 urban subzones, 14:59 rural subzones, and 29:59 remote subzones.
A comparison of actual response times for the ambulance agencies and the composite target response
times expected from the composition of urban, rural, and remote incident zone that comprise their
districts is presented in the table below.
Chili, Point Pleasant, and Rush are the three bright spots in this table. Chili, Rush and Point Pleasant
respond quicker than the composite target.12 Rural/Metro responds faster than the requirements of its
contract. Rural/Metro responds 24 seconds slower than the 8:59 expected of a district comprised of
100% urban subzones. However, 17 seconds of this delay is due to County Dispatch taking 2:02 instead
of 1:45 to get the request for service to Rural/Metro.
12
Point Pleasant no longer operates an ambulance.
Monroe County is designed as are many systems are in New York State, to follow the concept of
ambulance districts. The ambulance districts are artificial boundaries that are designed to set a specific
responsibility for ambulance service to a specific zone. These districts are totally autonomous and, as
such, are responsible for care, coverage and billing for ambulance service. What was built to protect the
citizens and give them autonomy of service has had an unexpected deleterious effect on the level and
consistency of service provided.
There are an excess number of ambulances and crews in Monroe County, especially among the smaller
ambulance services. Despite the excess capacity, but because the agencies operate with hard
boundaries, many of the EMS agencies in Monroe County under perform as judged by a comparison of
total response time against nationally accepted standards. A factor that further contributes to the long
total response times Monroe County is the existence of long agency processing times. The Consultant
speculates that the long agency processing times represent the time required by the local dispatcher to
assemble a complete crew for an ambulance. It is Consultant’s experience in other EMS systems that
this is a common experience for agencies that staff with a predominance of volunteers.
Currently, the two private for-profit agencies (Rural/Metro and Monroe Ambulance) hold countywide
certificates of need (CONs). Each of the remaining ambulance services holds a CON for its primary
response territory. Under current interpretations and applications of Article 30, it is not possible, without
change in either the law, the status of the CON holders, or via some other approach, to send the closest
appropriate ambulance to a request for service.
There are additional issues at play. The current City of Rochester contract provides for exclusivity for
Rural/Metro within the city limits. The City may or may not be open to modifying those provisions to
accommodate for response by closest units (regardless of agency) at the edges of the City. At the same
time, if the suburban and rural agencies had AVL they would be afraid of getting caught in the
“downtown vortex” that is often created around hospitals – where ambulances depart the hospital and
become in-service, and then are “caught” by the AVL system and assigned to additional center-city calls.
The plan has been tested over the years. Twice a year the County stands up the Emergency Operation
Center for federal and state observed drills related to the Ginna Nuclear Power Plan. What often results
is that will be shelter in place or an evacuation of one of the facilities and the Plan is exercised to see
what resources are available real-time to complete transportation. Typically emergency ambulances will
transport where gaps are identified. Should multiple nursing homes be taken off line in a critical event,
there would be an even greater need to utilize 911 dedicated ambulances to fulfill the mission. In the
short term, this situation would likely negatively impact the EMS system until spare ambulances and
staff could be called in for response.
13
http://www.health.ny.gov/professionals/ems/policy/mut_aid.htm).
The impact of Monroe County ambulance services is generally not measured, nor are performance and
outcomes data made available to the public. The internationally recognized Utstein Template measures
cardiac arrest save rates. None of the EMS physicians interviewed were able to document the cardiac
arrest save rate for patients using this template. Additionally, they were not able to report on the
performance of the aggregate of Monroe County EMS agencies against the most common EMS clinical
performance benchmarks – the “Eagles Benchmarks” developed by the Metropolitan EMS Medical
Directors Consortium of the United States. 14
Monroe County has no single, countywide electronic patient care reporting (ePCR) system. Each
ambulance service independently contracts for an ePCR system, which serves as the repository for all of
that service’s clinical and operational data. A few smaller agencies still utilize paper records. Agencies
perform their own internal quality reviews, to whatever degree they deem appropriate. Quality
performance data is not integrated. In interviews with medical directors, not one was able to answer the
extent to which generally accepted clinical performance measures are met either for the County as a
whole or for individual EMS agencies.
14 Evidence-based performance measures for emergency medical services systems: a model for expanded EMS benchmarking.
Myers, Slovis CM, Eckstein M, Goodloe JM, Isaacs SM, Loflin JR, Mechem CC, Richmond NJ, Pepe PE; U.S. Metropolitan
Municipalities' EMS Medical Directors. Prehosp Emerg Care. 2008 Apr-Jun;12(2):141-51.
The County EMS Office should assume responsibility for medical direction of all EMS agencies in the
County, and should be empowered with local legislation to promote the functioning of the system to
specific metrics of performance.
Empowered with local legislation, the County EMS Office should mandate a centralized, uniform
electronic Patient Care Reporting system, or at the minimum, should require all agencies to participate
in the Regional Health Information Organization (RHIO) data repository. Data in the repository is to be
verified and analyzed. The RHIO EMS depository could be enhanced to include an expanded data set,
including the National EMS Information System (NEMSIS) 3.x software when it becomes available, and
“special studies” capabilities. In addition, the County, in cooperation with the medical directors, should
regularly report typical operational performance metrics and clinical performance metrics per Utstein
and the Eagles’ benchmark standards.
Empowered with local legislation, the County EMS Office should require all EMS agencies to provide a
complete patient care report (not an abbreviated “drop sheet”) on all patients prior to departure from
the emergency department, unless there is an extraordinary situation (disaster declaration, etc.) The
County should work with RHIO and others to develop and implement bidirectional data exchange that
uploads ePCR data directly in to the physician electronic medical record, and provide emergency
department/hospital discharge outcomes data directly back to the ePCR data base.
Given the expertise of the Rochester Health Information Organization (RHIO) and Monroe County’s
strong academic health care community, it is practical and possible to build an integrated EMS
information system that links CAD data, ePCR data, and hospital outcomes data, without great difficulty.
The first concern was with hospital capacity. Each of the major hospitals in greater Rochester reports
operating at or in excess of 100 percent of its capacity nearly every day. This typically refers to the ability
of the hospital to handle an increased patient load using its regular, daily compliment of equipment,
staff, and policies in relation to licensed or staffed bed counts.
The second concern addresses surge capacity as contemplated by the New York State Department of
Health. This evaluation is in relation to each hospital’s “surge plan,” in which special equipment, staff,
and policies are activated in response to an “event.” Each hospital has identified surge areas outside of
their emergency department to begin treatment for less injured or less salvageable victims, designated
specific activities that will be cancelled or delayed to allow use of their space and/or staff to support
surge, and devised means to evaluate the quick discharge or transfer of inpatients to make room for
incoming victims.
Rarely would these activities take place due to a “busy day” unless activity exceeded certain thresholds.
There are reported instances of a couple of hospitals instituting “surge procedures” due to
overcrowding without a specific event as a trigger. Although the smaller rural hospitals are less likely to
be operating at or over capacity on a regular basis, their resources are equally limited to be able to surge
enough to take up the slack of the region.
The Department of Health has reported that all hospitals, generally speaking, are proportional in their
ability to surge and respond. The concern here is that the tipping point for activation of surge plans is
much lower when hospitals are operating at higher volumes and with leaner staff. During “surge
period,” many busy and important services (such as same day surgery and other outpatient processes)
would be altered to meet the needs of the event and provide the required surge capacity. 15 This is not
sustainable in the long term.
The third “surge capacity” discussion dealt not with hospital beds, but with emergency department
capacity and ambulance offload delays. This issue was clearly the concern of EMS leaders, EMS medical
15
The State Health Department reports that the U.S. Department of Health and Human Services has recommended that a
region have an “event” surge capacity of 500 beds above daily operating count per million persons. They reported to the
interview team that each evaluation of the region’s ability to meet this standard had found it possible to do so.
All three of the surge issues have come to bear recently due to the current active influenza season. The
New York State Department of Health issued a letter in January 2013 regarding the marked increase in
influenza patients presenting to hospital emergency departments. The letter, provided as Attachment B,
discusses hospital overcrowding and specifically addresses the delays to ambulance services in
transferring patients to hospital staff. “Ambulances and accompanying EMS personnel are not to be
detained in the emergency department and should be placed promptly back into services . . . ambulance
patients must be transferred promptly to emergency department staff.”
This results in not only an unnecessarily increased demand for services (often uncompensated), but also
results in those medical services being provided in the most expensive manner possible: transportation
in an emergency ambulance when a less-costly mode would be sufficient, and treatment in the hospital
emergency room when a lower acuity and less costly venue would be more appropriate. The costs are
borne not only by those directly involved, but also by the community as a whole.
Against this backdrop, EMS systems with strong clinical leadership began several years ago to explore an
expansion of evaluation and decision-making capabilities of local EMS systems. Instead of simply
responding and transporting all callers, more appropriate transportation modes and destinations could
Monroe County examined this issue several years ago, and a “Priority Four Diversion Project” was
undertaken. This project was concluded after some small design defects were noted to interfere with
the desired outcomes 16, but the concept remains viable. There remains great interest in the EMS,
emergency medicine, and community health arenas in further exploring options to utilize EMS
paramedics as part of this effort. Both the Finger Lakes Health Systems Agency (Senior Planner Arthur
Streeter, M.H.A.) and the Monroe County Public Health Director (Andrew S. Doniger M.D., M.P.H.) have
history with the earlier project and believe that it should be pursued. That sentiment was shared by all
of the hospital emergency department directors, and much of the EMS community.
The Finger Lakes Health System Agency (FLHSA) is a community-independent health planning
organization, serving the City of Rochester and the Finger Lakes region. FLHSA has been awarded a
multi-year grant in excess of $26 million by the Centers for Medicare and Medicaid Services “Health
Care Innovations” grant program, for a community-wide, outcomes-based payment model for primary
care that will serve Medicare and Medicaid beneficiaries in six counties in the Rochester, New York area.
The project creates a collaborative of agencies, payers, employers, government, patients, social
coalitions, and community service organizations to integrate community services with primary care and
leverage social and health care resources.
Primary care physicians will receive technical, process, and adaptive support, and will be connected with
a team of care managers, care coordinators, and community health workers. This approach will
strengthen primary care and reduce avoidable hospitalizations, readmissions, and emergency room use.
Over a three-year period, the Finger Lakes Health Systems Agency will train 726 health workers and hire
76 health care agencies in positions as care managers, community health workers, community-based
care coordinators, and practice improvement advisors. 17
It is important that the County and all EMS agencies develop a strategic approach to community
paramedicine, as an alternative to ambulance transportation and emergency department treatment for
those who call 911 with sub-acute and chronic health conditions. The County can collaborate closely
with the FLHSA to assure that EMS fulfills its potential to reduce unnecessary hospitalizations, hospital
re-admissions, and unnecessary emergency department use.
16
The Monroe County effort involved the ambulance paramedic in the alternate destination decision, as well as the
transportation to alternate destinations (which often required more time than a simple hospital transport.) Other programs,
such as those in Fort Worth, Texas and Wake County, North Carolina, utilize another resource – the community paramedic or
advanced practice paramedic – to make this decision, thereby taking the decision-making away from the ambulance paramedic.
This keeps the clinical decision separate from the individual, whose workload is impacted, allowing for better decision-making.
Other programs perform alternate destination transportation using vehicles that are less expensive than a paramedic
ambulance, such as a taxi or paratransit van, when the patient’s condition is less acute.
17
http://innovations.cms.gov/Files/x/HCIA-Project-Profiles.pdf
The Rochester RHIO Executive Director, Ted Kremer, provided the consultants with his vision of the
future for the Rochester RHIO as it pertains to EMS agencies and the individual provider. His thoughts
are summarized below.
As we move forward in making critical patient information available at the point of care, integrating EMS into
regional and national health information exchange (HIE) strategies needs to be an area of focus. Even though
the adoption of digital records by EMS agencies has not seen the same national focus and funding that
hospitals and physician practices have seen, they represent a key part of the health care delivery system.
Including EMS agencies into a larger health information exchange strategy necessitates that we establish
interoperability with the software technology companies serving this market.
There is a core set of interoperable functionality that should emerge from the integration of pre-hospital care
system as they connect with local, regional or state health information exchanges.
§ EMS agencies should be able to send to an HIE not only completed ePCRs but should also be able to
send biometric reading from ancillary devices (ECG, pulse oximetry, BP readings, etc.).
§ EMS data should be available to a patient’s treating providers through an HEI. This includes calls that
resulted in patient transport as well as treat and release calls that did not result in patient transport.
§ A physician should be able to subscribe to, or be notified of, emergency events involving their patients.
Such notification should either be sent directly to the physician’s electronic medical record through an
HIE or utilize the Office of National Coordinator’s “Direct”’ messaging protocol.
§ EMS agency personnel should be able to query and retrieve a patient’s Continuity of Care summary
document from an HIE in high priority calls. Such a document should contain patient demographics,
medications, allergies, problem list and advanced directives such as Do Not Resuscitate (DNR) or
Medical Orders for Life-Sustaining Treatment (MOLST).
§ This Continuity of Care document should be both readable and the ePCR system should allow for
populating appropriate fields in the agency’s ePCR.
§ In evaluating care trends and moving towards quality outcomes, analytical services looking at care
measures should include EMS-based services and link them to subsequent hospital utilization or other
outpatient care trends to better understand the complete picture of both patient and the complete
picture of patient care.
Mr. Kremer’s comments underscore that urgent need for Monroe County to move towards an up-to-
date and fully functional, integrated Computer Aided Dispatch system and unified ePCR system.
Fitch was able to ascertain that two major ambulance agencies have provided emergency and non-
emergency medical response and transport for over a decade and without tax or other subsidy. Both
organizations maintain up-to-date, sophisticated CAD systems and deploy in an efficient and dynamic
manner.
The City of Rochester has successfully conducted several procurements for the provision of emergency
medical services. The Rochester market has proven sufficient to attract competition resulting in no
subsidy, performance-based contracts. The greater Monroe County area provides sufficient transport
revenue streams to sustain both organizations.
The remaining ambulance agencies are supported by a combination of transport fees, local tax and
other subsidies, monetary donation and volunteer staffing donations. The consultants were not
provided with detailed financial documents from the ambulance agencies in Monroe County. However,
based on our experience in like-sized communities, it would be unusual for ambulance agencies that
operate in relatively small districts to be totally supported by patient transport revenue. The area
outside the City limits of Rochester, in aggregate, could potentially support one or several coordinated
ambulance agencies. This concept will be explored in the options section of this report.
18
The ambulance count was provided by the County EMS Office.
The table provides comment about the Monroe County EMS systems on a total of 50 specific items.
Of the 50 benchmarks, 14 are outside the scope of this review. Of the remaining 36 benchmarks, the
Monroe County system affirmatively meets 13, receives a definite “No” on 13 benchmarks and has
partial recognition for 10 benchmarks. Clearly, there is room for improvement.
CLINICAL BENCHMARKING
Best practice EMS systems review clinical data frequently and down to the level of the individual agency
and the individual provider. There was no evidence that Monroe County EMS agencies conduct
appropriate, ongoing clinical benchmarking and/or quality improvement that is shared with the County
EMS Coordinator or the County Medical Director. Rural/Metro is required by contract to monitor
quality/clinical metrics and share these with the City’s Medical Director.
911/MEDICAL COMMUNICATIONS
Best Practice Benchmarks for Communications
EMS dispatch centers are considered the coordination centers for EMS systems; they take calls with
complex call taking algorithms, categorize and prioritize calls, and then assign the appropriate resource.
Best practice EMS dispatch centers are designed to accommodate Public Emergency Reporting Services
(PERS) and phase II network-to-network interface of wireless agencies. These mandatory connections
facilitate wire-line, cellular, voice over internet protocol, automatic crash notification, patient alerting
system devices and other public 911 access to the Emergency Medical Services System. Voice, video,
telemetry, and other data communications conduits are utilized as necessary to best enhance real-time
information management for patient care.
Quality in dispatch centers is established through continuous quality improvement that, at the front
end, is medically directed. These medically directed systems use protocol based emergency call taking.
The most commonly used protocol based call taking system is Emergency Medical Dispatch (EMD).
Nationally recognized performance standards exist for each part of the call taking process (see prior
section titled Call Processing Attributes and Standards). These standards provide a yardstick against
which the performance of the communications center can be measured. Technology should support the
caller and direct the call from the primary Public Safety Answer Point (PSAP) to the appropriate
secondary PSAP for the geographic location of the call.
The collection of comprehensive data on performance and the routine reporting of this data are key
elements of quality in a dispatch center. Routine reports on performance become the foundation for
performance measurements that are the accountability standards by which the service will be
considered as adequate, excellent or failing in its delivery of service. Technology should support the
Calls located in the Monroe Ambulance district or Rural/Metro district are sent electronically to
dispatchers at either Monroe or Rural/Metro. These dispatchers are then responsible for allocating the
calls to an ambulance waiting on station.
In the case of call locations other than in the Monroe Ambulance, Rural/Metro, and a few other districts,
the Monroe County 911 Dispatch Center is responsible for ambulance dispatch. They initiate a call to the
indicated ambulance service district, and the ambulance agency responds with a verbal
acknowledgement. In the event of “no response,” some agencies have a prescribed five-minute wait
time before the Dispatch Center tries to get a response from one of the neighboring ambulance districts.
The Dispatch Center will not wait if the ambulance district has no ambulance logged on or if the logged-
on ambulance is on a call. This does not mean that they are selecting the closest ambulance, as it is
often not the case. The dispatch center is blind to vehicle movements and cannot select the closest,
most appropriate vehicle to the call. Logons into the system are done through a County-created web
page. The system has many operational advantages, yet it is totally passive, maintains no records and
provides no data.
In this section we describe and contrast the differences between the Monroe County 911 Dispatch
Center and best practice. A specific focus is put on dispatch technologies, processes in the dispatch
center, medical priority dispatch and quality improvement, and electronic patient care records (ePCR).
The principle communication center is equipped with an antiquated Northrop Grumman CAD system
that does not integrate rostering, automatic vehicle location (AVL), global positioning system (GPS), and
other important components. Even more alarming than the incomplete data that the Northrop
19
The County should make the new trunked radio system available to both Monroe Ambulance and Rural/Metro. The County
will need to determine user fees to be reimbursed and each agency will be responsible for portables/mobiles, etc.
20
The Monroe County 911 Center (Emergency Communications Department of the City of Rochester) has been accredited in
past years, but is not listed on the National Academies of Emergency Dispatch website as a currently accredited center of
excellence.
21
Both Monroe Ambulance and Rural/Metro have offered their AVL view to County Dispatch Center. To date, County Dispatch
has declined the offer.
The figure below is an example of a demand and coverage map. Hot spots of call demand are color-
coded and coverage is determined by showing the drive zone capability from specific posts or stations.
Currently, Monroe County does not have data connectivity into the field and instead, it relies on voice
communications for all vehicle information exchange, be it activity tracking (call assign, depart for call,
arrive on scene, etc.) or pertinent patient information exchange. This means that all time stamps and
Electronic PCRs transfer data several ways and to several recipients. They first supply an electronic or
paper record to the receiving hospital through Wi-Fi or Bluetooth technology. They supply system
information to administrators either in real time over cell tower connections or through Wi-Fi/
Bluetooth/docking station back at the base. This data is parsed and sent to the relevant recipient, be it
medical control, billing, or operations.
Alarmingly, many ambulance services in Monroe County leave no record of patient contact at the
receiving hospital. This is a serious lapse in patient care and may have liability consequences to the
ambulance service agency and the receiving hospital.
Understanding the medical dispatch center’s role is the key to interpreting how the processes are core
to the success of an EMS system. The dispatch center must be able to provide sophisticated real-time
deployment and re-deployment of resources. It must engage callers in medical interrogation and
intervention. It is the primary source for information necessary to manage the system for the benefit of
patients. The figure below depicts the critical communication functions of a 911 call center.
As can be seen in the figure above, there are distinct and critical functions in the dispatch operation. In
best practice systems at least five of these functions (i.e., deployment, medical call reception,
categorization, prioritization, and resource assignment) are governed by EMS dispatch. In some systems,
the control of hospital destination is also governed by EMS dispatch.
While the Monroe County 911 Dispatch Center has a coordination role, it does not play its role as a
dispatch center holistically. It does not have full control of the locations of ambulance resources and
cannot reassign them to uncovered areas. The Monroe County 911 Dispatch Center has limited control
on destination management. This often results in overwhelming specific hospitals and underutilizing
others. Each of the functions in the figure above roles has activities and tasks associated with them as
illustrated in the figure below.
In the Monroe County 911 Dispatch Center, call handling takes longer than specified by the nationally
accepted best practices. There is a lack of real-time data transfer between field operations and dispatch.
There is an inability to deploy available units to optimize coverage due to limitations imposed by existing
state policies. The table below provides a side-by-side comparison of industry best practices with
Monroe County 911 Dispatch Center practices.
The Monroe County 911 Dispatch Center fully performs only five of 13 best practices, partially performs
three and fails to perform five practices. Implementing an up-to-date, fully integrated CAD system is the
first step in addressing poor performance system-wide.
Dispatch Personnel
Fitch & Associates was asked for its opinion of the resources required for dispatch center operations.
Fitch reviewed the report prepared by the Monroe County 911 Dispatch Center on staffing requirements
and agrees with the methodology applied. However, making decisions on staffing appears premature.
The existing Northrop Grumman CAD system is antiquated and does not optimize the dispatch process.
As such, personnel are compensating for inadequate technology. The appropriate time to review staffing
is after the existing Northrop Grumman CAD system is replaced.
In the long term, a change to the state EMS regulatory structure could resolve this issue. New York State
has a long history of home rule, village-centric municipal governance, that was once quite functional but
which does not align well with modern concepts of regionalized health care and EMS delivery. 22
In the meantime, one viable option involves the County itself obtaining a CON for ambulance service
throughout the County. Utilizing the provisions of Public Health Law § 3008, the County could obtain a
countywide CON. Utilizing the authority of its CON, the County could provide centralized coordination
and management services, and could enter in to service area agreements with each of the existing
ambulance services to serve particular subareas within the County. Those agreements could include
provisions governing “closest unit dispatch” and address other operational improvements. This new
organization could also facilitate the development of countywide EMS special operations capabilities,
which are sorely needed as noted elsewhere in this report.
22
See, “Emergency Medical Services At the Crossroads”, Institute of Medicine, National Academies, June 2006, recommending
the delivery of EMS on a regional basis.
Within Monroe County, EMS providers have varying degrees of training and experience supporting
public safety special operations teams. Everything from scene awareness to treatment of patients would
benefit from specialty-trained medics. There are some EMS providers trained in support of law
enforcement SWAT teams, but there are too few to provide consistent 24 hours/7 day- a-week
coverage. Other providers are trained in Advance Hazmat Life Support, but not in other special
operations areas.
A current program that was spearheaded by Monroe County EMS involves a formal assessment of
special operations capabilities and development of training modules. The University of Rochester is
completing the assessment and development phases of the program. The goal of the program is to
cross-train a group of providers in all special operations areas. The result would be that, for example, a
provider who responds to a bomb squad incident that turns into a hazmat incident is prepared and
trained to support in both areas (as well as others).
The program is funded to include reviewing County Response Plans, developing modifications to take
advantage of EMS Special Operations, integrating the program into the Plans and accomplish training
through CY2012 and CY2013.
At the same time, the ambulance services have evolved sufficient leadership to support their daily
functions. The leadership effort focuses primarily on staffing transport ambulances, recruiting and
maintaining ambulance personnel, and the myriad details that are involved in operating an ambulance
service on a day-to-day basis. Probably because most of the day-to-day ambulance activity involves one-
patient, one-contact, one-transport, and because of the small size of the organizations involved, there
has not developed a focus in incident command — National Incident Management System
Into the patchwork of ambulance services that serve the County, the County EMS office has evolved a
small group of volunteer deputy County EMS coordinators also known as “battalion coordinators,”
whose functions are primarily advisory, both to the County and to the ambulance services. Operational
coordination, where it occurs, is provided by the deputy County EMS coordinators, operating under the
general supervision of the County EMS Coordinator. In a major incident, these coordinators will be slow
to respond (as they are at-home volunteers with day jobs), and have no authority to direct, but merely
serve as advisors and resources to local ambulance service and the municipality having jurisdiction. This
was evidenced by the lukewarm performance of the EMS system generally at the Greater Rochester
International Airport drill (see 2008 and 2011 airport drill reports for evidence of lack of progress).
During the course of this study, the Consultant had an opportunity to observe a full-scale exercise
involving a simulated aircraft crash at the Rochester International Airport. Although the planning of the
exercise did not meet current guidelines for the planning and evaluation of exercises, 23 the exercise
provided an opportunity to test the infield response and incident management capabilities of the local
EMS community. The airport’s emergency operations center was impressive, stood up quickly, and
provided excellent support throughout the event.
Although incident command was appropriately provided by the airport’s crash-fire-rescue officers, the
EMS component of the event was not well-organized at the field level. A significant illustration of
suboptimal resource utilization was the fact that the County’s EMS physician, present in his field
response role and properly outfitted for assignment, was never assigned a function, remaining in a
staging location throughout the event. There was no evidence of any personnel accountability for EMS
personnel on site.
The evolution of Monroe County’s patchwork of independent ambulance services to a fully functional
EMS system will require the building of an empowered infrastructure responsible for major incident
planning and management, special team and project coordination, quality management, operational
analysis and reporting, and support to the office of the medical director as that function evolves.
23
The Homeland Security Exercise and Evaluation Program (HSEEP) constitutes a national standard for all exercises. Through
exercises, the National Exercise Program supports organizations to achieve objective assessments of their capabilities so that
Strengths and areas for improvement are identified, corrected, and shared as appropriate prior to a real incident. See
https://hseep.dhs.gov/pages/1001_HSEEP7.aspx.
When dealing with emergency medical services, it is essential to understand the concept of the
“probability of a call” or the “probability of a demand for service,” herein referred to as “risk.” The
metric for risk is (calls/square km/month). The mistake that many policymakers make is to believe that
risk is attached to census-derived population densities, where communities deemed “rural” by a
planning or census definition carry low risk for emergency medical services.
In emergency medical services, census-derived population density has proven to be only a relative
predictor of demand for services. This is primarily due to the fact that many regions in the County are
“bedroom communities.” The population of the “bedroom community” affects other areas that have the
working populations. Simply put, not everyone has their emergency event at home. This effect is
exemplified by the numbers for the City of Rochester: per the United States Census, only 28% of the
domiciled population of Monroe County lives in Rochester. Yet as presented in this report, 48% of all
EMS calls in Monroe County originates within the City of Rochester.
The Consultant used a “clean canvas” approach. None of the existing infrastructure was considered.
Further analysis would be required to ascertain which of the existing buildings might be used as stations
in this model.
To be defensible, any model for delivery of emergency medical services to Monroe County must be
designed to perform to what has been institutionalized as best practices by most high- performance
systems in the United States and Canada. The arrival of a transport capable ambulance should occur
within a clinically appropriate time frame 24. For the M-xR Model, this parameter has been set to the
following metrics:
§ Less than nine minutes (8:59) on life-threatening emergencies (Echo and Delta type calls) in
areas of Urban call densities,
§ Less than fifteen minutes (14:59) in areas of Rural call densities,
§ Less than thirty minutes (29:59) in areas of Remote call densities.
Note that performance metrics are applied to urban, rural and remote areas that are designated based
on call densities and are not based on population densities.
Response time should be measured in a consistent fractile manner (nine times out of ten, or 90%
reliability) as opposed to average (five times out of ten, or 50% reliability). Response times for non-life
threatening assignments and inter-facility transports should be set by the County EMS Office with
capabilities to monitor and publically report compliance to standards.
The Consultant obtained raw dispatch records from the County’s Northrop Grumman Computer Aided
Dispatch (CAD) System for CY2010 and CY2011. Using proprietary algorithms, Fitch removed duplicate
24
Dr. Joseph Fitch, JEMS, June 25 2007, “Response times: Myths, Measurement & Management.”
http://www.jems.com/article/communications-dispatch/response-times-myths44-measure
Temporal volume of activity is calculated by dividing the call volume by a standard notion of time
(month, week, weekday, hour etc.). For this analysis, the call volume was divided by days and hours to
get an average demand per day of week and an average demand per hour of day. How the demand for
service changes with day of week is presented in the figure below. How demand for service changes by
hour of day is presented in the figure below. (These figures are viewable at larger scale in Monroe
County System description earlier in this report.
There is some fluctuation in demand from Sunday to Saturday, but it is less than ten percent. For
purposes of the model in this report, these day-by-day fluctuations in demand are small enough to be
disregarded. If an implementation analysis is required, these day-by-day fluctuations need to be
considered more closely in order to match resources to demand.
There are three steps to determine urban and rural incident zones:
1. Use the predetermined political boundaries of Monroe County excluding the City of Rochester
as the mapping area.
2. Import the historic data for demands for service onto this map.
3. Create a grid of one-kilometer (1km) squares that covers the area to be evaluated. For all
squares in the 1km grid, the analysis counts the number of incident locations that fall within
each square. For each 1km square, the analysis also determines the number of incidents that fall
within the eight adjacent 1km squares in the grid. This methodology removes the artifact or
potential that a singular address, such as a nursing home, can affect a square to such a degree
that it becomes Urban (high density demand) without truly exhibiting high-density demand over
the whole square.
The outcome of this process results in the map of incident zones presented in the figure below:
§ RED: Urban Incident Zones—two calls per square kilometer per month with at least half the
adjacent square kilometers having the same number of calls per month.
§ GREEN: Rural Incident Zones —at least one call per square kilometer every four months with at
least half the adjacent square kilometers having the same number of calls per month.
§ WHITE: Remote Incident Zones —less than one call per square kilometer every four months.
Three characteristics are noteworthy regarding the figure above of incident zones, based on call
densities for Monroe County:
1. High demands for service (Urban risk) extend significantly out into the County beyond
the geographic limits of the City of Rochester.
2. Medium demands for service (Rural risk) occur in only a moderate number of the zones in
Monroe County and represent a smaller portion of total calls.
3. Low demands for service (Remote risk) occur in very few of the zones in Monroe County and
represent a very small portion of the total calls.
The figure below lists the EMS agencies dispatched during the period of the data dump and indicates the
percentage of incident zones based on call density that quality as “Urban”, “Rural” or “Remote”
according to the RED, GREEN and WHITE legend above.
25
Areas labeled City Contract 1, 2 and 3 are not relevant to this analysis and should be disregarded.
Very few of the agency districts are comprised of a single type of incident zone. Almost all of the districts
are comprised of a mix of incident zones with urban incident zones predominating. Only three agency
districts have less than 15% urban zones. The preponderance of urban incident zones is much greater
than perceived by system participants.
The impact of urban incident zones on the functioning of the system is greater still. An urban incident
zone generates at least eight times the number of calls as a rural incident zone. In almost every district,
the total call activity for the district is dominated by the activity occurring in the urban incident zones.
26
Areas labeled City Contract 1, 2 and 3 are not relevant to this analysis and should be disregarded.
Figure 20. Call and Drive Zones for “M-xR” Monroe County Excluding Rochester
Detailed descriptions of the locations of these ambulance stations are listed in the table below.
Table 31. Ambulance Location for the M-xR Model Excluding Rochester
Post Urban or Total Percent
Rank Location Post Capture Drive Time
Number Rural Capture Capture
1 1443 near Towpath Motel/Monroe U 36043 36043 16.45% 7
near Fairport Village Justice Court/14 W
2 1588 U 25754 61797 28.21% 7
Church St, Fairport, NY 14450
3 994 near House of Hsu/House of Hsu U 25098 86895 39.67% 7
near Di Bella's Old Fashioned/Di Bella's
4 1655 U 22874 109769 50.11% 7
Old Fashioned
5 1187 near Bazil/Monroe U 19143 128912 58.85% 7
near Nick's Imports and Meat
6 1459 U 15631 144543 65.98% 7
Market/1354 SR-386, Rochester, NY 14624
near Guida's/North Ave, Webster, NY
7 924 U 11088 155631 71.05% 7
14580
near Richardson's Canal House Inn/516
8 1795 U 7503 163134 74.47% 7
SR-96, Pittsford, NY 14534
near Parma Town Justice Court/1071 SR-
9 647 U 6182 169316 77.29% 7
18, Hilton, NY 14468
near Gordon Steak and Crab
10 785 U 5745 175061 79.92% 7
House/Monroe
near Portico Bed and Breakfast/8399 SR-
11 862 U 5156 180217 82.27% 7
104, Brockport, NY 14420
There are more stations identified than there are ambulances required. Due to dynamic deployment,
ambulances will not be on standby at all stations at all times of day. Eighteen of thirty ambulance
stations are at locations serving areas of Urban call densities. Twelve of thirty ambulance stations are at
locations serving areas of Rural call densities.
There are two key observations regarding the location of ambulance stations in this model:
§ With only 16 ambulances on standby at these stations, 90% of Urban demands for service and
90% of Rural demands for service are covered in the prescribed time.
§ Additional ambulances on standby at additional stations do little to improve performance and
reduce response times.
With 16 ambulances on standby, 90 percent of demand coverage can be achieved in the allocated time
interval. With 20 ambulances on standby, coverage increases to only 95%. Adding ambulances causes
the system to saturate and enter a regime of rapidly increasing costs.
The fact that it was possible to find optimum locations for ambulance stations in the M-xR Model shows
that the geography and call densities of Monroe County do not intrinsically prevent achievement of the
8:59 and 14:59 response times required to meet nationally accepted standards.
Figure 10 located in the Agency Processing Time section, presents the flow of an EMS call in Monroe
County. The interval of time indicated as T3 -> T8 is referred to Time-On-Task. This interval reflects the
time a unit spends responding to and returning from a request for service. During this interval the unit is
not available for coverage.
Fitch concluded that the data for Time-On-Task available from the County’s Northrop Grumman CAD
was unreliable. The next best source for relevant data is Monroe Ambulance Service because they have
a reliable CAD, have a Countywide CON and responds to more than 13,000 of all calls in the County. In
2011, Monroe Ambulance Service reported its Time-On-Task as 68 minutes.
For purposes of constructing this model, Fitch decided to use a Time-On-Task of exactly 60 minutes in
order to ease comprehension of the model by the reader. The difference between 60 and 68 minutes is
only 13%, and is well within the margin of uncertainty of a model constructed at this level detail.
With this principle in mind, the Consultant performed an analysis to determine the number of
ambulances and crews needed in the M-xR Model. The historic demand data show variations in demand
for service that are insignificant by day of week. However, variations in demand for service are
substantial by hour of day.
The changes in demand that occur hour-by-hour are significant to the M-xR Model and are explicitly
accounted for in the table below which tabulates call volume per hour, the number of ambulances
passively waiting on station to answer a call for service (coverage), and the number of ambulances
actively responding to a request for service.
The total number of active units required by the M-xR Model varies from a low of 20 at 5:00 a.m. to high
of 29 at noon. A “unit hour” refers to an ambulance and its crew being in service for one hour. The
Optimized M-xR Model requires 620.3 unit hours per day, or 226,410 unit hours per year. A requirement
of 620 unit-hours per day represents a temporal adjustment of -11% off of the maximum number of unit
hours, calculated as if the maximum number of units had to be in service all day long (29 units x 24 hour
= 696 unit hours/day).
There is insufficient data available to Fitch & Associates at this time to distinguish the proportionate
contribution of each possibility or to merely distinguish between these possibilities.
Further aid may be afforded the individual ambulance agencies by centralizing billing at the County level
and having the County disburse reimbursement payments to the ambulance agencies. Cost
normalization based on out-of-jurisdiction call activity needs to be provided. Centralized purchasing at
the County level may also be an aid.
Estimate of Costs
The analysis in this section is intended to provide an estimated operating cost of the Optimized M-xR
Model System. The “back-of-the envelope” approach to our estimate is based Fitch’s experience with
other systems and repeated finding that the largest single component of operating costs is that of an
Fitch & Associates did not have access to financial data for the 28 ambulance agencies across Monroe
County. It was not possible to obtain a blended average based on actual hourly costs for a unit-hour as
currently experienced by ambulance agencies in Monroe County. Fitch & Associates was compelled to
rely upon two limited sources of information to estimate a county-wide cost per unit-hour.
The first was a report published in 2011 by Scottsville, NY EMS Chief Mathew Jarrett titled, “Town of
Wheatland and Village of Scottsville, Financial Analysis and EMS Delivery Options.” In this report, the
personnel cost of a fully staffed ALS ambulance (one advanced care paramedic and one basic care
paramedic) was reported as $65 per hour. Based on Fitch’s experience with other systems, a unit hour,
fully burdened with administration, benefits, and depreciation, will come in at 50% over labor cost
alone. In this case, the fully burdened cost per unit hour becomes $97.50/hr.
The second resource, informal conversations between Fitch & Associates and several of the ambulance
agencies using paid staff, yielded multiple estimates of the fully burdened cost per unit-hour that
centered around $100.
The confluence of these two sources of information convinced Fitch & Associates to use $100 as the
fully burdened cost per unit hour. That said, some agencies, specifically those that use a large portion of
volunteer paramedics, probably experience a much lower cost per unit hour.
The table below presents the estimated annual cost of the Optimized M-xR Model performing to
nationally accepted standards of response times in areas of both Urban and Rural call densities. The
number of unit hours drops down from the table above titled Units Required by Hour of Day above. The
cost per unit hour is as discussed above.
Table 33. Estimated Annual Cost of a Fully Paid Optimized M-xR Model
System Model Unit Hours/Year Cost/Unit Hour Cost/Year
M-xR Model 226,410 $100/ unit-hour $22,641,000
27
Based on survey responses from 20 of the Monroe County ambulance agencies, five used volunteers for field and chief
operating officer positions, nine were a combination of paid and volunteer and only five utilized all paid personnel.
The antiquated Northrop Grumman CAD system is not capable of generating reports listing how many
ambulances were online by month, by day, or by time-of-day. To fill this gap in data, Fitch & Associates
went back to the raw data dump from the CAD, selected a single day at random, and manually tallied
ambulances online for that day. The result was a maximum of 85 units per hour. 28 To give the existing
system the benefit of the doubt, we applied a -22% temporal adjustment, double the temporal
adjustment seen in the Optimized M-xR Model resulting in the unit hours per year presented in the
table below.
The table below compares the estimated operating cost of the Optimized M-xR Model with the
estimated “virtual cost” of the existing system in Monroe County.
Table 35. Comparison M-xR Model Cost and Existing “Virtual Cost” of Current System
System Unit Hours/Year Cost/Unit Hour Cost/Year
Optimized M-xR Model System 226,410 $100/unit-hour $22,642,200
Existing System (Monroe County, 580,788 $100/ unit-hour $58,078,800
excluding Rochester)
The extraordinary result is that the “virtual cost” of the existing operations in Monroe County is 2.6
times greater than estimated cost of the Optimized M-xR Model.
Estimates of Revenues
For ambulance services, transports are the primary source of revenue; other lesser sources include
subsidies, donations and in-kind or indirect support. Transports are divided into inter-facility transports
28
The consultants validated this number with the County EMS Office that indicated there are 87 ambulances servicing the area
excluding the City of Rochester.
Past experience with inter-facility transports leads to our expectation that they are a positive stream of
revenue to the Optimized M-xR Model. The principal reason for this expectation is that the transporting
ambulance agency has the ability to validate the facility’s ability to pay prior to proceeding with the
transport.
In contrast, emergency transports exhibit a significant spread between gross billings and net revenues,
as can be reasonably collected by the billing agent. In large cities where the collection rate is low, it is
common to collect net revenues of approximately 40% of gross billings. In suburban and affluent
communities, it is more common to receive a higher ratio, often as high as 60%. These collection rates
were validated by ambulance agencies in Monroe County as realistic estimates of what they are
collecting today.
In order to estimate the gross revenue per emergency transport, as billed, Fitch & Associates used data
from a Coalition of Advanced Emergency Medical Systems (CAEMS) report published in 2009, as
tabulated in the table below. The gross revenues for each agency were inflated from 2009 to 2012 as
indicated, which results in an average of $956.41 per transport as noted in the table below.
Fitch & Associates next went back to the raw data dump from the Northrop Grumman CAD and
determined that there were 76,806 emergency transports in Monroe County, excluding Rochester, in
the time frame of the model.
A revenue stream was estimated based on this number of transports and the gross billing per transport
as tabulated in the table below. To be conservative, the collection rate was assumed to be only 40%.
Operation of Monroe County, excluding the City of Rochester, under the Optimized M-xR Model System
is conservatively estimated to generate $29 million per year in revenues (assumes all transports are
billed).
The lesson to be learned from the process of constructing the M-xR Model is that emergency services in
Monroe County, excluding the City of Rochester, can be managed in such a way as to meet nationally
accepted standards of performance AND be revenue neutral. With this result as background, prepare
detailed specifications and performance standards defined by zone and for the overall system and put
emergency services in Monroe County, excluding the City of Rochester, out to competitive procurement.
Fitch & Associates expects that the contracting agency will use a dynamic deployment model that has
the characteristics of the Optimized M-xR Model System described herein.
Many of the existing ambulance vehicles may be acquired by, or could partner with, the new service
agency. Many of the existing volunteer positions could convert to paid positions. Costs to the County are
expected to be very small. Costs to the municipalities are expected to be very small. The new contractor
may be required to reimburse the County for certain services and thereby become a source of revenues.
The following EMS agencies identified by the EMS Coordinator as providing ambulance transport
were sent a survey tool in late October 2013. The list indicates which agencies responded in a
complete manner to the survey and those that did not.
EMS Agencies That Responded EMS Agencies That Did Not Respond
Brighton Volunteer Ambulance Brockport Ambulance
Xerox Ambulance
Fire first response (non-transporting) agencies were identified by the EMS Coordinator and sent
a survey tool in late 2012. The table below indicates those that responded in a complete manner
and those that did not.
Fire Agencies That Responded Fire Agencies That Did Not Respond
Brockport FD Fishers FD
Chili FD Kodak FD
Egypt FD Mumford FD
Fairport FD Ridge-Culver FD
Hamlin FD Rush FD
Henrietta FD Scottsville FD
Hilton FD Walker FD
North Greece FD
Spencerport FD
Union Hill FD
As you are aware, New York State has seen a marked increase in influenza patients
presenting to hospital emergency departments. Ongoing conditions of hospital overcrowding
have served to further strain the ability of hospitals to manage the current patient influx.
Overcrowding in hospitals and emergency departments (EDs) can directly impact a hospital’s
ability not only to meet community needs, but also to respond to peak periods of critical need.
With the increased attention and commitment to emergency preparedness, we must refocus our
efforts on the continuing issue of hospital overcrowding.
Despite these surge and overcrowding conditions, EDs must remain open to ambulances
and must maintain the capacity to accept new emergent patients in order to ensure that the
capabilities of our health care system as a whole can, when called upon, respond, unless
otherwise authorized to go on diversion. As you are well aware, overcrowding affects ongoing
service delivery, and can have a negative impact on the quality of patient care. The enclosed
guidelines have been developed to advise hospitals of expectations and responsibilities in regard
to maintaining the capacity to respond to, and manage, emergency health care needs throughout
the year.
Please review the enclosed documents and ensure that your institution has in place
appropriate policies and procedures to implement these responsibilities. Your immediate and
continuing attention to this critical matter is of utmost importance. Thank you for your
anticipated cooperation.
Sincerely,
Attachments
GUIDANCE DOCUMENT FOR HOSPITALS
Overcrowding / Emergency Preparedness
Hospital Obligations & Responsibilities
Hospitals must meet the needs of the communities they serve on an ongoing basis. It is the
responsibility of the hospital’s Governing Body and Senior Management personnel to
review the following guidelines to help relieve overcrowding, and to implement, as
appropriate. Additionally provided is CMS guidance that describes options hospitals may
use to facilitate relief of ED surge that fall under existing EMTALA requirements (no
waiver required).
• Hospitals should use all available inpatient beds in managing admissions from the
emergency department. Maintaining admitted patients within the emergency department
is not acceptable. Hospital administration must be proactive in identifying and utilizing
inpatient beds for admissions from the emergency department. All hospital beds and
inpatient areas should be identified and considered in determining bed assignments.
During peak periods of overcrowding as a temporary emergency measure, hospitals
should activate their facility surge plans and make use of planned, non-traditional surge
spaces as necessary to alleviate hospital overcrowding, e.g., placing beds in solariums
and hallways near nursing stations.
• Hospitals are required to have in place effective monitoring protocols to track and
identify length of stay patterns and deviations, both for inpatients and for patients in the
emergency department. Priority attention should be given to initiating inpatient and
emergency department discharge planning activities to ensure the prompt and safe
discharge of patients. Efforts to coordinate with community resources, nursing homes,
and other patient support services should be in place and functioning at all times.
• Ambulances and accompanying EMS personnel are not to be detained in the emergency
department and should be placed promptly back into service. To ensure that patient care
needs are met by hospital staff, ambulance patients must be transferred promptly to
emergency department staff.
• Hospitals should evaluate staffing levels on a hospital-wide basis. Cross training and
coordination among programs and services is necessary to ensure adequate staffing levels
during peak periods of need.
• Hospitals must assume responsibility for the quality and appropriateness of all patient
care services. Regardless of the location within the facility, staffing, services, privacy,
infection control and confidentiality protections must be consistently in place.
• Hospitals must make available to ED staff the ancillary services which permit the prompt
disposition of patient care needs. The 24-hour availability of transport services is
necessary to meet patient needs and to allow for the timely transfer of admitted patients.
• Elective admissions/surgical cases projected as requiring short term (or longer) use of
inpatient beds should be postponed, until inpatient beds have been assigned to the
emergency department patients waiting for beds.
• Neighboring health care institutions should be surveyed as to their capacity for accepting
transfers from the hospital.
DEPARTMENT OF HEALTH & HUMAN SERVICES
Centers for Medicare & Medicaid Service
7500 Security Boulevard, Mail Stop S2-12-25
Baltimore, Maryland 21244-1850
FROM: Director
Survey and Certification Group
SUBJECT: Emergency Medical Treatment and Labor Act (EMTALA) Requirements and
Options for Hospitals in a Disaster
Memorandum Summary
In anticipation of a possible significant increase in demand for emergency services due to H1N1
influenza resurgence this fall several Federal agencies, State health departments, and hospitals
have expressed significant concerns about compliance with EMTALA requirements during an
outbreak. Many stakeholders perceive that EMTALA imposes significant restrictions on
hospitals’ ability to provide adequate care when EDs experience extraordinary surges in demand.
The attached fact sheet clarifies options that are permissible under EMTALA and should
reassure the provider community and public health officials that there is existing flexibility under
EMTALA. Among other things, the fact sheet notes that an EMTALA-mandated medical
screening examination (MSE) does not need to be an extensive work-up in every case, and that
the MSE may take place outside the ED, at other sites on the hospital’s campus.
The fact sheet also summarizes the provisions governing EMTALA waivers. Surveyors and
managers responsible for EMTALA enforcement are expected to be aware of the flexibilities
hospitals are currently afforded under EMTALA and to assess incoming EMTALA complaints
accordingly in determining whether an on-site investigation is required. They are also expected
to keep these flexibilities in mind when assessing hospital compliance with EMTALA during a
survey.
Page 2 – State Survey Agency Directors
Questions about this document should be addressed to CDR Frances Jensen, M.D., at
frances.jensen@cms.hhs.gov.
Training: The information contained in this letter should be shared with all survey and
certification staff, their managers, and the State/RO training coordinators immediately
/s/
Thomas E. Hamilton
Attachment
DEPARTMENT OF HEALTH & HUMAN SERVICES
Centers for Medicare & Medicaid Service
7500 Security Boulevard, Mail Stop S2‐12‐25
Baltimore, Maryland 21244‐1850
FACT SHEET
I. What is EMTALA?
• EMTALA is a Federal law that requires all Medicare-participating hospitals with dedicated
EDs to perform the following for all individuals who come to their EDs, regardless of their
ability to pay:
- An appropriate medical screening exam (MSE) to determine if the individual has an
Emergency Medical Condition (EMC). If there is no EMC, the hospital’s EMTALA
obligations end.
- If there is an EMC, the hospital must:
+ Treat and stabilize the EMC within its capability (including inpatient admission when
necessary); OR
+ Transfer the individual to a hospital that has the capability and capacity to stabilize the
EMC.
• Hospitals with specialized capabilities (with or without an ED) may not refuse an appropriate
transfer under EMTALA if they have the capacity to treat the transferred individual.
• EMTALA ensures access to hospital emergency services; it need not be a barrier to providing
care in a disaster.
• The MSE does not have to take place in the ED. A hospital may set up alternative sites
on its campus to perform MSEs.
- Individuals may be redirected to these sites after being logged in. The redirection
and logging can even take place outside the entrance to the ED.
- The person doing the directing should be qualified (e.g., an RN) to recognize
individuals who are obviously in need of immediate treatment in the ED.
• The content of the MSE varies according to the individual’s presenting signs and symptoms.
It can be as simple or as complex, as needed, to determine if an EMC exists.
• MSEs must be conducted by qualified personnel, which may include physicians, nurse
practitioners, physician’s assistants, or RNs trained to perform MSEs and acting within
the scope of their State Practice Act.
• The hospital must provide stabilizing treatment (or appropriate transfer) to individuals
found to have an EMC, including moving them as needed from the alternative site to
another on-campus department.
• Hospitals and community officials may encourage the public to go to these sites instead
of the hospital for screening for influenza-like illness (ILI). However, a hospital may not
tell individuals who have already come to its ED to go to the off-site location for the
MSE.
• Unless the off-campus site is already a dedicated ED (DED) of the hospital, as defined
under EMTALA regulations, EMTALA requirements do not apply.
• The hospital should not hold the site out to the public as a place that provides care for
EMCs in general on an urgent, unscheduled basis. They can hold it out as an ILI
screening center.
• The off-campus site should be staffed with medical personnel trained to evaluate
individuals with ILIs.
• If an individual needs additional medical attention on an emergent basis, the hospital is
required, under the Medicare Conditions of Participation, to arrange referral/transfer.
Prior coordination with local emergency medical services (EMS) is advised to develop
transport arrangements.
C. Communities may set up screening clinics at sites not under the control of a hospital