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1 Lehigh Acres Fire Control & Rescue District Office of the Fire Chief Fax Memorandum To: Board of Fire Commissioners From: Donald R. Adams, Sr., Fire Chief Date: October 8, 2009 Re: ALS Transport Verses ALS Non Transport During the August 17, 2009, Special Budget Meeting, I was asked my opinion on the direction of the District. At that point I expressed a service delivery model of maintaining the ambulances and laying off 36 firefighters in an attempt to balance the budget. Since that time several other factors have come to light. It is estimated that the citizens of Lehigh Acres will contribute $1,300,000 to Lee County EMS in the 2009/2010 budget. During the last five years the citizens have paid $6,546,574 to Lee County for an ambulance service with minimal return on investment other than the rare instances when Lee County transported a patient from within the District s boundary. At that point the patient is also responsible for a user fee in addition to the taxes already paid. Since the reduction of fire and EMS apparatus as a result of the layoffs, Lee County EMS has been responding into Lehigh Acres almost daily and transporting patients to area hospitals. Nonetheless, there is still a high degree of satisfaction with the District s EMS among the people of Lehigh Acres. Interviews and focus groups with service clubs and Lehigh Leadership all confirm the public s very positive attitude toward the District s pre hospital system. At the same time, throughout the District we still need to improve system quality and performance at all levels. Many of the issues the District is facing are whether to provide an excellent ALS transport service or an excellent fire service due to the decline in revenue. The question of the District providing the ALS ambulance service or Lee County providing the ambulance service is an example. One view point is the argument that District personnel are typically the first to arrive at an incident and that they provide critical patient care in the initial stages of a medical emergency and should be the one to continue treatment while en route to the hospital. Further, fire personnel would have to assist Lee County ambulance crews by aiding in patient care en route to the hospital taking the fire apparatus out of service. Lastly, the District would not receive compensation for their crucial services if they do not physically transport the patient to the hospital. Thus, further reducing revenue and possibly placing the District into a deficit in the near future if the economy continues to decline. Another related question is whether Lee County EMS should be granted exclusive rights to the entire area of Lehigh Acres or should the District maintain at least one ambulance. Such a program might be

2 2 appealing to some since it could offer a uniformity of service countywide while still maintaining one District ambulance. However, with 74 personnel total for the District and approximately 24 of those being on shift could reduce staffing levels on ALS engines during peak times due to leave usage. The only option would be to brown out a station during that period of time or reduce staffing levels down to two personnel on an ALS engine. This would place the District s firefighter s lives at risk according to NFPA 1710 and the Commission of Fire Accreditation International. In addition, this could open the District to legal proceedings. Given the complex inter organizational relationships involved in the EMS system of a large county, it is unrealistic to expect all the elements to work without friction. However, if the District relinquished the ALS transport services, it is crucial that the disparate entities work in harmony for the benefit of the citizens of Lehigh Acres. My responsibility is to provide each of you with a critical element in the assessment of our emergency service delivery system and the ability to provide adequate resources for the anticipation of medical emergencies or fire related events. Each emergency requires a variable amount of staffing and resources in order to be effective. Controlling a fire before it reaches its maximum intensity requires a rapid deployment of personnel and equipment in a given timeframe. The higher the risks to the community the more resources and personnel needed; whereas, medical incidents require fewer resources and personnel. Creating a level of service requires making a decision regarding distribution and concentration of resources in relation to the potential demand placed upon them by the level of risk to the community. When factoring in all the potential demands for basic level care, advanced level care, maximum on scene times, a standard care for response to life threatening incidents, a standard for response to fire related incidents, available revenue, firefighter safety, and the obligation of the District to provide a fire suppression service, I would have to support re opening Station 105 and allowing Lee County EMS to provide ALS transport services. BACKGROUND INFORMATION FOR AN INFORMED DECISION Mission of the District The range of services provided by the District today is termed all hazards. The fire service is no longer just about responding to emergencies. Everything that we do supports a key portion of our mission, which is service above self through delivery of fire suppression services, continued fire training, fire safety education and delivery of Advanced Life Support. To the District, this means making a commitment to providing assistance in both expected and unexpected ways. To accomplish this, the primary goal of the District is to maintain a community that is safe from fire by reducing losses to life, health and property. Community Perception There is a high degree of public satisfaction with the District providing ALS transport. This fact has only been confirmed by residents interviewed in service clubs and those calling or those paying bills in person. Nonetheless, there have been some complaints regarding the cost of the service and not the quality or level of care. On the other hand, there has only been one complaint regarding ALS transports provided to the District by Lee County EMS. That complaint was regarding response times for transport. Both agencies have a laudable sincere desire for quality improvement throughout the EMS professional community. The vast majority of the county's residents have a high degree of satisfaction and faith in the emergency medical services system provided by both agencies.

3 3 ALS Transport The question of who should provide ALS emergency transport is passionately being debated throughout the United States. Fire agencies argue that they are strategically deployed 24 hours per day and can typically arrive on scene more quickly than non fire ambulance services. Many fire based ambulance agencies further argue that they are not motivated by profits and are able to act solely in the best interests of the patients. Others take the position that a service so crucial to the health and safety of the people should be provided by one agency for the good of the community. Many ambulance providers believe that they provide a higher level of service because they can focus on EMS only instead of having to maintain both fire and EMS certifications. These providers raise legitimate questions regarding the dilution of skills that ensue by having to maintain so many disciplines of study. In addition they argue a single ambulance provider could lead to easier coordination of service, uniformity of quality, and a reduction in fragmentation. However, there are benefits from a fire service providing ALS transport. Impact on Patient Outcome The greatest positive impact on the outcome of life threatening EMS events resides with Advanced Life Support (ALS) arrival time within 8 minutes or less from the time of alarm. This positive impact is not based on if the first arriving unit can transport or not. It is based on initial care provided. Nonetheless, due to the size of the District this response time cannot be achieved through the entire District without a greater saturation of resources. Acceptable Standard for EMS Responses There is no universally accepted national standard for EMS responses. However, some historical general standards from NFPA 1710 have been adopted: (1) A turnout time interval of 1 minute or less 90% of the time, (2) A response time interval of 4 minutes or less for a BLS EMS unit 90% of the time, (3) A response time interval of 8 minutes or less for an ALS EMS unit 90% of the time. The American Heart Association Chain of Survival outlines actions that must be taken in order to successfully resuscitate victims in out of hospital cardiac arrest. The measure for EMS must be considered in two different ways: (1) The first consideration is how fast basic life support can be provided to citizens who suffer from cardiac arrest. American Heart Association studies have shown that cardio pulmonary resuscitation (CPR) must begin immediately, and in all cases no later than 4 6 minutes of a cardiac arrest. Early defibrillation (AED) must then follow early CPR. These actions must be followed up by advanced life support in order to provide advanced coronary care. The combination of late CPR (more than four minutes) and late advanced life support (more than 12 minutes) is particularly lethal. Several researchers have called these time dimensions the resuscitation failure zone. (2) The second consideration is early advanced life support intervention for patients that are not yet in cardiac arrest, but have a cardiac rhythm that will become lethal if not treated rapidly. In addition, the Pre Hospital Trauma Life Support (PHTLS) guidelines state that for life threatening trauma type incidents, emergency medical providers should be en route to the nearest trauma center within 10 minutes of arrival of the first responder. The PHTLS guideline is based on an analysis of trauma related incidents which are most critical when determining how quickly an ambulance should be en route to the hospital.

4 4 Distribution of Resources Given the reality of current health care economics, it is unrealistic to expect an increase of acute care beds in the future which will result in slower off load times. The majority of hospitals in Lee County are, in fact, all located in the County's highest population areas. In addition, because of the significant redistribution of financial resources by hospitals and the manageable health care problems they are facing, patient off load times will become an emergent problem in the near future. Thus, adding additional time to the District s units being out of service and out of the District. Parochialism To expect all elements of the EMS system, if the District does not provide ALS transport, to work together without friction or disputes is unrealistic. The various personnel involved will probably have different priorities, personalities, work ethics and shared values. In many cases, the individual personalities may feel they are in direct competition with one another. However, it is crucial to the public that the disparate entities work in harmony to deliver their life saving services at the most effective and efficient level possible. While legitimate inter agency differences must be acknowledged and respected, these differences must not be permitted to undermine the functioning of the system as a whole. Officers from both agencies will have to mediate disputes and must be held accountable for effective facilitation. Impact on Budget and Revenue If the District does not provide ambulance service the net revenue for 2009/2010 will decrease by approximately $1,000,000. This will cause the District to use $1,000,000 out of the Operating reserves for 2009/2010 bringing the reserve total to $7,460,021. The estimated reserves for 2010/2011 would be $3,278,583 with the projected drop in revenue for that year. The District will be in the red for the projected budget year of 2011/2012 by ($2,771,274) with 74 line personnel, 3 battalion chiefs, 1 mechanic, 1 inspector and 8 administration personnel estimating a 5% decrease in revenue. Impact of No Ambulances The effect of committing fire apparatus to EMS calls more frequently would create a negative impact on fire response by reducing the available fire units needed to meet initial response apparatus and personnel to meet present National Fire Protection Association (NFPA) and Accreditation standards and need to be weighed against the level of fire suppression calls and availability of other system resources. Fire Dynamics and Sequence of Events Most structure fires are fairly predictable unless influenced by highly flammable material. The sequence of events from point of ignition to flashover is approximately five minutes. Flashover has a dramatic affect on the outcome of a fire and the ability of firefighters being able to control the fire before it does damage to the structural integrity (framing) of a building. Building materials today have a much greater potential to produce rapid spread of a fire than in previous years. Once the District is notified, the longest element of the response is to the scene allowing the fire to intensify. Once on the scene firefighters have to position their apparatus, lay out hose lines, don SCBAs and additional equipment, perform various other task before they can make entry into the building to extinguish the fire. With reduced staffing levels these tasks seriously challenged firefighting operations and place firefighters at risk. Emergency Medical Dynamics and Sequence of Events The most significant medical life threatening event is a cardiac arrest. The victim of cardiac arrest has mere minutes in which to receive definitive care. Percentage of change of recovery from a cardiac

5 5 arrest drops quickly as time progresses. Rapid CPR and early cardiac defibrillation is the most important element in care. According to the American Heart Association s Chain of Survival, a delay in transport is not part of their matrix for their chain of events in saving a cardiac arrest victim, it is the rapid response and rapid Advanced Life Support treatment. Nonetheless, no one would argue the point that early arrival to Emergency Room physicians would not be the most optimum system. Insurance Services Office (ISO) ISO focuses specifically on the firefighting capabilities of an individual community. ISO utilizes the Fire Suppression Rating Schedule (FSRS) to grade or review the fire fighting capabilities of a community. Although ISO ratings do not directly affect the fire department, they do affect fire insurance premiums for property owners within the District s response area. The schedule measures the major elements of a community's fire suppression system and develops a numerical grading called a Public Protection Classification. Currently, Lehigh Acres Public Protection Classification is a 4/9. On the other hand, a decrease in the FSRS primarily affects premiums for commercial occupancies, which could have an adverse impact on development in Lehigh Acres. Many companies often look at the fire protection classification rating of a fire department when they are considering relocating their business. Therefore, the community objective may be to acquire the necessary resources to achieve a more favorable fire protection class rating in the near future. The FSRS utilized by ISO gives no credit for ambulances. However, if they carry minimal fire suppression equipment partial credit is received. Fifty percent of the overall grading is based on the number of engine companies and the amount of water a community needs to fight a fire. Although, not all insurance companies use FSRS as a schedule to estimate insurance rates they use similar grading methods and often utilize a more complex system. The FSRS is only one area in a matrix of decisions in determining fire insurance premiums. Actual fire loss in terms of dollar amount is also a determining factor utilized by many insurance carriers. Several insurance companies have stated if Lehigh Acres closes a fire station then those residents around that station would either have an increase in premiums or their policy would be cancelled. In addition, several insurance agents supposed a method of choice for establishing premiums in banding of classes. This means for Lehigh Acres, as a Class 4 in areas around the fire station, commercial insurance premiums will remain the same, as long as Lehigh Acres rating stays the same. Insurance premiums will increase if the ratings decreased to 5 or even lower (the higher the number the lower the rating up to a 10). It is estimated that dropping from a Class 4 to a Class 5 rating may incur a twopercent increase in commercial fire insurance costs. On the other hand, it is important to recognize the fact that although maintaining or improving the District s ISO class rating would be a positive step; however, this does not guarantee that all insurance premiums will decrease, as this determination is ultimately up to the individual insurance providers writing the policy. NFPA 1710 (National Fire Protection Association) NFPA 1710 is a document which contains only mandatory provisions using the word shall to indicate requirements and is in a form generally suitable for mandatory reference by another standard or code or for adoption into law. If an agency adopts the standard as a code or ordinance then the intended use and form becomes enforceable with administrative provisions. Nonetheless, the District has not adopted NFPA 1710 as a mandatory provision. Therefore, it is to be used as a recommendation. The first recommendation is to maintain and include a minimum of four personnel including an officer on fire apparatus used for suppression. If quint or truck companies are expected to perform multiple

6 6 roles, such as truck company functions, staff them with greater than four personnel to ensure that those operations can be performed safely, effectively and efficiently. The second recommendation is if a fire company s primary function is to deliver and pump water and extinguishing agents at the scene of a wildland fire it shall be known as wildland companies. These companies shall be staffed with a minimum of four on duty personnel. The District currently utilizes two personnel on brush/wildland fire apparatus. The recommendation for minimal staffing on a fire scene (residential structure) is 15 firefighters and if an aerial device and pump are in operation the minimal required are 17 firefighters for a full alarm assignment. This assignment shall be deployed within eight minutes (480 seconds) from time of call. Compliance with the standard objectives regarding staffing and response times contained within this standard in difficult for most areas of the District due to time and distance. Risk Assessment Methodology The District must assess risks based upon the potential frequency (probability of occurring) and the potential damage, should it even occur, in the decision of providing ambulance or providing fire protection. The overall potential damage from medical emergencies to the community as a whole is not nearly as significant as that from a natural disaster or fire. The District must be able to compare the potential frequency and potential damage of an event that may affect the community as a whole. Although structure fires and wildland fire are relatively infrequent in comparison to medical incidents, the subsequent dollar loss, loss of irreplaceable items, and loss of business or jobs make the consequences of such fires high. Demand versus Coverage There are two basic service philosophies in the fire service: demand based coverage and geographicbased coverage. Geographic based coverage assumes citizens of the jurisdiction are entitled to reasonably equitable fire and emergency services regardless of where they may live. Whereas, demandbased coverage acknowledges that all life and property is of equal value and attempts to keep available resources close to the next most likely emergency to occur. Both of the philosophies apply to the closure of Station 105. Geographic for Station 105 would be based on protection and workload (call volume) becomes a distant second factor. It essentially focused on being able to cover an area regardless of the frequency of responses required. This philosophy only exists when all the resources are ready to respond. A limitation to this philosophy is mitigated by having ambulances outside of the District on transports and reducing coverage. Demand based protection is focused on workloads and the geographical area becomes a lesser issue. Demand attempts to answer emergency incidents in the least amount of time as possible by having apparatus available in high demand areas. Time is the most significant outcome of any emergency. Again having ambulances outside the District affects the workloads by reducing the number of firefighters on the scene of an emergency affecting the demand based protection. Staffing for Risk Protection Operation at the scene of an emergency is the most critical preservation of life and property. Sufficient staffing levels must be available on scene to perform all the tasks required to effectively control an

7 7 event, whether it is a fire or emergency medical incident. However, operation on a fire is based on the number of occupants, their location, location of the fire and the ability to take preservation actions. This requires a sufficient number of firefighters to deliver the water to extinguish the fire and allow firefighters to make entry to rescue occupants. Tasks that must be performed on a typical residential fire with one room involved which is considered moderate risk are: command (1 person), search and rescue (minimum of 2), water supply (minimum 1), ventilation (minimum 2), scene safety (minimum 1), fire attack (minimum 2), pump operation (minimum 1), back up (minimum 2) and RIT (minimum 2). However, according to the Commission on Fire Accreditation International s standard the number for moderate risks is 13 firefighters; high risk, fully involved house fire is 17 firefighters; and a maximum risk commercial fire is 49 firefighters. With our current mode of operation the District cannot meet the minimum standard established by the Commission of Fire Accreditation International if two or more ambulances are busy transporting patients. OPTIONS Option 1 Change the ALS response model to ALS engines provided by the District and ALS transport units provided by Lee County EMS. Thus, allowing Station 105 to be reopened as a fire station providing service to the southeast area of Lehigh Acres. This option allows for a maximum of 24 personnel to be on duty unless personnel are on a Kelly day, vacation time or sick leave. Then the minimal staffing level is 15 firefighters (three on an engine). There could be times that staffing on apparatus may be reduced down to three personnel. Option 2 Maintain the current level of service with four ALS engines and three ALS transport units. This option allows for maximum of 24 personnel to be on duty unless personnel are on a Kelly day, vacation time or sick leave. Then the minimal staffing level is two on an ambulance and two on an engine (14 firefighters). There could be times that apparatus will be browned out due to falling below minimal staffing. Option 3 For a trial period of three months provide one ALS transport unit and reopen Station 105. This would allow both agencies to determine the cost savings and inter organizational cooperation through the level of services provided. This option allows for maximum of 24 personnel to be on duty unless personnel are on a Kelly day, vacation time or sick leave. Then the minimal staffing level is 17. However, this option will increase the chance of reducing staffing to a minimal of three personnel on a more frequent bases and could even drop staffing levels below two on an engine during peak usage of leave. References: Center for Public Policy Studies. (1999). Emergency Response: Stanislaus County EMS. Emergency Services Consulting Group. (2000, September). City of El Paso de Robles Growth Management Plan. International Association of Fire Fighters. (2002). NFPA 1710 Implementation Guide.