Single Provider vs Multiple Providers

[46Young]

I didn't see a general EMS forum, so I decided to post this topic here:

I'm wondering what your thoughts are on whether it's better to have one sole provider responsible for EMS ground txp in a particular jurisdiction, or to have numerous. Reasons why would make for an interesting discussion, of course. A county run third service would be a typical example of the former, and FDNY EMS with all of it's voluntary hospitals along with Transcare and AMR being an extreme example of the latter. I'm not considering mutual aid txp units as an example of multiple providers. In medium to large size municipalities, the mutual aid may amount to only 5% of call volume, maybe less.

For example, the NYC 911 system has FDNY EMS, a bunch of voluntary hospitals, and two privates that are also contracted by hospitals. I feel that this creates problems regarding QA/QI standards, hiring and training standards, discipline, morale, and mother-may-I protocols. I was looking at the NYC Remsco protocols the other day, to compare them to what I'm working with down here. I forgot how llimited they were. Most of the stuff they need to call OLMC for is in our standing orders, and we can also do more in general. I believe that this is due to the numerous 911 providers in the city. The type of employee can vary greatly from one service to the next. Since the FDNY can't speak for the education and training of other providers, these protocols are made to have everything pass through a doc-in-the-box, just in case.

[zippyRN]

How many providers is not the issue assuming there is appropriate audit, assessment and enforcement of the providers to ensure a reasonable standard of care is provided by all the providers...

The key has to be how the system as a whole is integrated and communicates - it doesn't matter if you have 1, 2, or 23 provider organisations as long as they appear to the 911/999 system as a single entity providing cover across the service area - this also means that provider organisations have to be able to fulfill their commitment in providing the cover they have allocated to them to provide to an acceptable level. This fits with the model of separation of 'production' of 'unit hours' i.e. physically having crewed resources in the right place at the right time with the right skill mix and 'distribution' of these 'unit hours' (by control /comms ...) ...

[Richard B the EMT]

Since the FDNY can't speak for the education and training of other providers, these protocols are made to have everything pass through a doc-in-the-box, just in case.

I ask for a clarification, here. To me, a "doc-in-the-box" is a freestanding ER/clinic, not physically a part of a hospital building, for basically "Fast Trak" type patients. Anyone who needs actual hospitalization from one of these locations has to be transported to a hospital somewhere else.

Are you using the phrase "doc-in-the-box" to refer to "On Line Medical Control"?

[RomeViking09]

Give you 3 examples from my limited time in EMS (3 years)

Example 1: a county with 2 services who rotated calls in the county and had set zones in the one major city, 1 service did not have 12-Lead, morphine, or CPAP on the truck (the city fire did have 12-Lead and morphine on their ALS non-transport units), the second service had both but did not carry as many drugs (did not carry Vasopresen, vapermil, or pre diluted D25 & D10 among others) Full ALS fire in the city, mixed ALS/BLS Fire in the county based on what town your responding with and what unit

Example 2: 2 hospital based services that split the zones in a county, service 1 had more drugs and standing orders but only has less than 1/3 of the county (does provide primary 911 for a 2nd county their hospital is not located in) the 2nd service has more man power and trucks and a good set of protocols but lacking some things (Medicated assisted Intubation, not the same as RSI, more advanced equipment, and the ability to transmit 12-Leads to both hospitals in the county) no ALS fire in this county

Example 3: 2 services that split the county based on the fire batt. Service 1 that covers 1 of the 4 batts has no CPAP but has medication assisted intubation, carries plavaix for chest pain and has more standing orders/protocols that do not require calling the ER. Full ALS fire in the county and all cities in the county

My view is full state or county controled protocols and standards are better for patients and not leaving it to chance about what service responds

[kohlerrf]

I didn't see a general EMS forum, so I decided to post this topic here:

I'm wondering what your thoughts are on whether it's better to have one sole provider responsible for EMS ground txp in a particular jurisdiction, or to have numerous. Reasons why would make for an interesting discussion, of course. A county run third service would be a typical example of the former, and FDNY EMS with all of it's voluntary hospitals along with Transcare and AMR being an extreme example of the latter. I'm not considering mutual aid txp units as an example of multiple providers. In medium to large size municipalities, the mutual aid may amount to only 5% of call volume, maybe less.

For example, the NYC 911 system has FDNY EMS, a bunch of voluntary hospitals, and two privates that are also contracted by hospitals. I feel that this creates problems regarding QA/QI standards, hiring and training standards, discipline, morale, and mother-may-I protocols. I was looking at the NYC Remsco protocols the other day, to compare them to what I'm working with down here. I forgot how llimited they were. Most of the stuff they need to call OLMC for is in our standing orders, and we can also do more in general. I believe that this is due to the numerous 911 providers in the city. The type of employee can vary greatly from one service to the next. Since the FDNY can't speak for the education and training of other providers, these protocols are made to have everything pass through a doc-in-the-box, just in case.

Yes you are absolutely right. I have a substantial amount of past experienced with NYC EMS and what you have to remember is that the larger the system is, with the more employees under its belt the more they have to dumb things down and cater to the lowest common denominator. Is kind of an inverse relation, the larger the system the simpler the patient care. the smaller the system the tighter the medical control the more the doctors feel comfortable with allowing the medics perform. While NYC does have other hospital running paramedics they are I believe the largest EMS employer in the city and more over they are union. The typical union civil servant while dedicated, is generally just interested in "work to rule" and not going above and beyond because frankly if he does the union contract prevents him from being compensated for it because everyone has to be paid according to the contract so why should he seek to better himself if he does not have to? This is the mentality that the medical control doctors have to expect. Although I believe life would run much smoother having one chief with many Indians i realized pt care suffers for it. I am for "patient care" and having smaller organizations with tighter medical control that perform on the razors edge of pre-hospital care. force paramedics to think rather than treat form a cook book.

Lastly, I'm not bashing NYC EMS the are a great service dealing with issues other systems will never have to. NYC EMS has now and in the past had many great medics (me being one of them) but they are limited by human nature and the magnitude their atypical system and for that they do a great job.