Sparks City Council Meeting 8/22/2016 2:00:00 PMMonday, August 22, 2016 2:00 PM
Council Chambers, Legislative Building, 745 Fourth Street, Sparks, NV
General Business: 9.7
Total Costs: $83,842.00
Fund: General Fund Account: 603525
Program: Emergency Services (100401)
Amount: $83,842.00 Budget Status: Budget Exists
Budget Correction Plan:
Fire Staff recommends a multi-year implementation plan with the initial implementation of the program to occur in FY17. FY17 expenses are calculated at 84,341.94. Current budget exists to cover these calculated expenses in Program 100401 - Account 603525. The cost of the three 12-Lead EKG Monitor/Defibrillators, $102,135.15, is funded through the department’s Capital Equipment Replacement Plan, Program 100404 - Account 603006.
A Business Impact Statement is not required because this is not a rule.
This proposal is for the City Council to consider the implementation of Paramedic level emergency medical service (EMS) in the Sparks Fire Department (SFD). In the fall of 2015, the fire department was instructed by the City Manager to investigate and report on whether Paramedic level service was needed in the SFD.
In order to answer this request from the City Manager, research was conducted to answer six key questions:
1. Does the fire department arrive on scene to EMS calls prior to REMSA’s arrival?
2. When the fire department is first to arrive, do they have to wait for REMSA long enough to have adequate time to deliver Paramedic level interventions?
3. On those EMS calls where the fire department arrives first and waits for REMSA’s arrival, is the nature of the medical emergency urgent enough to warrant that the fire department personnel initiate Paramedic level interventions?
4. Do medical recommendations or standards exist that indicate Paramedic level interventions should be started immediately with the arrival of the first responders?
5. Do other reason exist that indicate Paramedic level service should be considered for the Sparks Fire Department?
6. If opportunities to improve patient care can be demonstrated, do these opportunities justify the expense to implement and operate a Paramedic program in the Spark Fire Department?
The research found that in the fifteen month period between January 1, 2015 and March 31, 2016, the fire department arrived on scene first to EMS calls 60.4% of the time; that the fire department waited an average of 3 minutes and 22 seconds for REMSA to arrive and that this average time increased as EMS calls occurred further away from the core of the City; and that just over 40% of the EMS calls where SFD arrived first and waited for REMSA were classified as ‘urgent’ based on the care provider’s determination of the medical emergency found based on patient assessment.
The research also found that since the year 2000, significant advancements in technology and medical practices have been made in the Paramedic scope of practice. These advancements have led to a gap between the level of care the Advanced EMT can provide, the current level in the fire department, and what the Paramedic level can provide, REMSA’s currently level. Patient care recommendations from the American Heart Association were also researched for guidance on when Paramedic interventions should begin. Recommendations were found that Paramedic level interventions should be started with the arrival of the first responders for specific medical complaints including cardiac, stroke, and respiratory emergencies; or that at a minimum, efforts should be strived for to shorten the time from recognition of a medical emergency to definitive care in the hospital.
Three other reasons to implement this program, other than medical, were then considered. It was explained that the Enhanced Automatic Aid Agreement with the Truckee Meadows Fire Protection District, an agreement designed to make auto aid more efficient and faster, would likely not be implemented due to the different EMT certification levels between the two departments. Also considered was the over-reliance on REMSA to provide Paramedic level service to the City of Sparks and that there was a need to create a back-up plan to provide this service during instances of extended wait times. And finally, it was stated that Sparks, being a full-service city, should strive to provide the best EMS care possible to the community and that the surrounding communities of Reno and Washoe County provide Paramedic level service.
The last question of whether the benefits of the program justified the cost to implement it were then researched. Although fire department staff firmly believes that a Paramedic program is justified in the fire department, a comprehensive one-time implementation of the program was determined to be cost-prohibiting. Fire staff proposed a multi-year method of transitioning to the Paramedic level in order to ease the fiscal impact, allowing more opportunities of having adequate funding for other priorities and projects in the City. Two multi-year plans were presented for Council consideration. Plan A is designed to transition the entire department to Paramedic level service within five years, with a pre-defined schedule of when additional districts would be staffed at the Paramedic level. This plan would result in the shortest transition time possible but necessitates a relatively aggressive funding commitment. Plan B is also designed to transition the entire department to Paramedic level service, but over a much longer period of time and without a pre-determined schedule to add additional districts. This plan eliminates several of the larger expenses included within Plan A resulting in less required funding.
The Sparks Fire Department is an all-risk response agency with core emergency services of fire suppression, rescue, hazardous material, and EMS response. Regionally, SFD participates in a two-tiered EMS response system. Responders from the fire department traditionally make up the first-tier response, providing rapid access and initial assessment and treatment to citizens and visitors of the City who have accessed the 911 system to report a medical emergency. The private ambulance company, REMSA, traditionally makes up the second-tier response, providing Paramedic level service and transport to local hospitals. This two-tiered system allows the community to take advantage of strategically placed fire resources to provide rapid initial assessment and treatment in order to stabilize and ready patients for transport. Another benefit of the two-tier EMS response is that this arrangement allows for longer response time standards for the ambulance provider, requiring less ambulance resources needed to meet their response time requirements. In theory, fewer ambulances needed in the system effectively controls transport costs to the lowest levels possible.
Because of the differences in the number and placement of fire vs. ambulance resources, fire responders usually arrive on scene first a greater percentage of time as compared to the ambulance resources. Since first-tier resources are tasked with initial assessment, treatment, and stabilization of patients, several factors have influenced the EMS certification levels of fire department responders. Historically, as the overall percentage of EMS calls has increased, the fire department has evaluated the need to increase its EMS certification levels. For example, in 1986 EMS was approximately 45% of the department’s overall call volume. At that time, fire personnel only received basic First Responder certification with skills in bleeding control, basic splinting, spinal immobilization, and oxygen therapy. By the year 2000, EMS calls had increased to 74% of overall call volume, and EMS certification was upgraded to the Advanced EMT level. This certification not only provided basic care but also some advanced care protocols, including intravenous needle placement, advanced airway interventions, and limited medication administration. Currently, EMS calls account for just less than 81% of the department’s overall call volume. The department is now considering an upgrade to the Paramedic level of EMS certification.
Another factor influencing an increase in EMS certification is the relative differences in patient care protocols between the first-tier responders and REMSA. In the year 2000, SFD personnel were certified to the Advanced EMT level and REMSA to the Paramedic level. In the last sixteen years, significant changes have occurred to the Paramedic scope of practice, expanding this scope with new technology, medications, and treatment. The scope of practice for the Advanced EMT, however, has remained relatively unchanged, leading to a widening of the gap between the two certification levels. A clear example of this is the capabilities of the 12-Lead EKG Cardiac Monitor/Defibrillator. This monitor allows the care provider the opportunity to ‘detect’ a heart attack earlier in the assessment process, including ST-Elevation Myocardial Infarction (STEMI), effectively shortening the time from recognition to definitive hospital care. This monitor/defibrillator can also provide manual defibrillation, transcutaneous pacing, and electronic cardioversion, allowing the EMS provider to immediately address a variety of life threatening cardiac dysrhythmias. Additionally, technology in the form of End Tidal CO2 (ETCO2) measurement, also known as capnography, has become the standard in airway placement confirmation, a critical component in airway management. ETCO2 is also used as an assessment tool, measuring the effectiveness of certain airway treatments, and is a critical tool during the management of cardiac arrests. SFD’s upgrade to Paramedic level service can close the current gap in EMS care, enabling the fire department to provide a higher level of patient care at the time of initial contact.
Given the increase in the number of EMS calls the department responds to, providing medical care at the Paramedic level should provide additional opportunities for SFD responders to positively affect patient outcomes.
Based on analysis, fire department staff believes the number of calls where the fire department is arriving first to urgent EMS emergencies and waiting a significant period of time for REMSA’s arrival, plus the fact that medical recommendations exist stating that Paramedic interventions should be started with the arrival of the first responders, indicate there are numerous opportunities to improve patient care by implementing a Paramedic program at SFD. Council has also been provided with three supplemental reasons to implement this program; that an Enhanced Automatic Aid Agreement with TMFPD could be implemented; that there will be a back-up plan to provide Paramedic care when REMSA is delayed; and that a Paramedic program is appropriate for a full-service city like Sparks. Therefore, fire department staff recommends that City Council implement Paramedic level service in the Sparks Fire Department.
The expense required to implement and maintain this program will need to be approved and supported by City Council, and dedicated funding should be earmarked for this purpose. Concerns have been raised that the funds needed for a Paramedic program may delay projects, programs, and expansion in other City departments. Fire department staff understands these concerns and is fully aware of the fiscal challenges facing the City. To reduce the fiscal impact to the lowest amount possible, allowing for other priorities within the City to be considered, but still addressing the community’s need for Paramedic level service in SFD, fire department staff recommends a multi-year implementation of the program. In order to further address fiscal concerns, two options were provided for Council to consider.
Plan A is designed to transition the entire department to Paramedic level service within five years, with a pre-defined schedule of when additional districts would be staffed at the Paramedic level. This plan would necessitate a relatively aggressive funding commitment by City Council, but would result in the shortest transition time possible. Plan A’s estimated cost is $1,902,313.55 through 2022 and $231,322.07 in subsequent years (in today’s dollars).
Plan B is also designed to transition the entire department to Paramedic level service, but over a much longer period of time, and without a pre-determined schedule to staff additional districts. Using attrition and the new-hire process to add Paramedic staffing to the department, plus allowing for adequate funding to accrue in the department’s Capital Equipment Replacement Program before purchasing new defibrillators, substantial savings as compared to Plan A can be realized. Since the fire department will be absorbing the cost to purchase defibrillators, this expense can be removed from the fiscal impact to the City resulting in the total additional cost to implement Plan B of $84,341.94 in FY17 (funding already budgeted for), $127,859.38 in FY18, and $116,338.04 in FY19. Fiscal year funding would remain at this level (approximately $116,000 in today’s dollars) until five new Paramedics could be hired through attrition in the fire department. At that time, sufficient Paramedic staffing would exist to allow for another district to be converted to Paramedic level service. Total cost to implement Paramedic service in the City’s three most critical districts (District L41, E51, and E21) - $328,539.36.
The need for this Paramedic program cannot be overstated, but neither can the need for new programs and staffing increases in other City departments. Fire department staff firmly believes a Paramedic program for the fire department is important and needed for this community, but understands there are other needs in the city that are important as well. For this reason, fire department staff recommends that City Council approve of the implementation of Paramedic level service in the Sparks Fire Department and that either Plan A or Plan B is acceptable. Although speed of implementation is a concern, the primary consideration is to have a plan to increase the level of patient care in the community and to put this plan in action. Although Plan B will take longer for full transition, it will immediately result in increasing the level of care in the City’s three primary districts of concern, lead to the implementation of Enhanced Automatic Aid, provide a back-up plan when REMSA is delayed, and support the concept of Sparks as a full-service city.
- City Council can choose to approve implementation of the Paramedic Program following the guidelines of Plan A.
- City Council can choose to approve implementation of the Paramedic Program following the guidelines of Plan B.
- City Council can choose to not approve the implementation of Paramedic level emergency medical services in the Sparks Fire Department.
I move to approve implementation of Paramedic level emergency medical service in the Sparks Fire Department, following the guidelines set forth in Plan _____.
Consideration of a Paramedic Program for the Sparks Fire Department - Revised.pdf
Paramedic Consideration Power Point Presentation - Revised.pdf
Paramedic Report Revision Summary.pdf