Part 3 - Alameda County Public Health Department

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SCHEDULE This ten-month professional development program includes three four-day on-site meetings, monthly conference calls, and a web-based follow-up session six months after graduation. In addition to the on-site meetings, participants engage in monthly conference calls, support and mentor one another via listserv, and receive individualized support from faculty. For details about the schedule, please visit www.IHI.org/IA. ENROLLMENT PROCESS To enroll, please go online to www.IHI.org/IA. Under the “Enroll” tab, you’ll find detailed instructions about the application process, which includes two documents: the Improvement Advisor Application and the Improvement Advisor Knowledge and SelfAssessment Form. Upon acceptance into the program, you will receive a prework packet to begin preparing for the first on-site meeting. Due to the intensity of the program and work on real projects for the participating organizations, class size will be limited. C H A N G I N G H E A LT H C A R E T O G E T H E R IHI is a not-for-profit organization leading the improvement of health care throughout

the world. IHI helps accelerate change by cultivating promising concepts for improving patient care and turning those ideas into action. Thousands of health care providers participate in IHI’s groundbreaking work. IHI offers a wide variety of programs and activities for health care professionals to

learn from expert faculty and collaborate with experienced colleagues around the world. This particular professional development program is part of a family of programs designed for leaders who seek to gain a particular set of skills that are required for an organization to succeed in its improvement agenda. Additional learning opportunities include worldclass conferences and seminars, web-based programs, and professional development programs exploring other critical leadership roles.

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20 University Road, 7th Floor Cambridge, MA 02138 (617) 301-4800 (866) 787-0831 www.IHI.org





Craig J. Brandt, RPh, MBA Director of Performance Improvement Northern Westchester Hospital, Stellaris Health Mount Kisco, NY

The course is organized to teach a concept, discuss its practical application in our own hospital’s operation, then to write actionable plans to apply the concepts in our organizations. I returned to my organization with tangible plans in my hand. Not just a bunch of good ideas. I feel much more confident leading people in our organization now that I have the tools and support from this IHI program.

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INITIAL STUDY OVERVIEW: CLINICAL IMPACT OF AMBULANCE RESPONSE TIMES FOR ECHO AND OTHER TIME-DEPENDENT EMS CALLS

The impact of response times has been a core aspect of EMS system design since the early 1980s when system pioneer Jack Stout read Dr. Eisenberg’s original study on cardiac arrest resuscitation. Jack built fractal response time performance requirements with financial penalties for failure to perform into the contracts he wrote for Public Utility Model EMS systems. EMS systems have evolved since Dr. Eisenberg and Jack Stout first began working with the concept of response time performance nearly thirty years ago. While the science of EMS has evolved, much is left to be learned about optimal system design. This series of studies explores the clinical impact of various ambulance response times for 9-1-1 calls classified as Echo and other time sensitive calls in an EMS system with ALS Fire First Response? We will work with the Alameda County EMS Agency and experienced clinical researchers to design a series of studies that shed more light on the impact of various response times. The results of these studies can be used to inform EMS system design including response time requirements in Alameda County and other EMS systems around the Country.

STUDY QUESTIONS: 1. Is there a difference in the Rapid Acute Physiology Score (RAPS) for patients where the transport ambulance arrives in 6 min or less, between 6 and 7 min, between 7 and 8 min, between 8 and 9 min, between 9 and 10 min, between 10 and 11 min, between 11 and 12 min, between 12 and 13 min, and over 14 min? 2. Is there a difference in the survival rate of patients where the transport ambulance arrives in 6 min or less, between 6 and 7 min, between 7 and 8 min, between 8 and 9 min, between 9 and 10 min, between 10 and 11 min, between 11 and 12 min, between 12 and 13 min, and over 14 min?

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HYPOTHESIS: There is no significant difference in RAPS scores or survival rates for Echo patients where there is a different ambulance response time.

LITERATURE: Eisenberg, MS, Bergner, L, Hallstrom, A 1979 Cardiac Resuscitation in the Community: JAMA May 4, 1979 Vol 241, No 18 This study focused on the impact of several time-related variables involving resuscitation from out-of-hospital cardiac arrest. The study focused on 569 patients with witnessed cardiac arrest. Their study determined that there was a strong relationship between discharge from the hospital with time to initiation of CPR and time to definitive care. “If CPR was initiated within four minutes, 97 of the 348 patients (28%) were discharged. If it took four or more minutes to initiate CPR, 25 of the 204 patients (12%) were discharged (P<.001). Discharge rates were similar up to a definitive care time of eight minutes. If the time to definitive care was less than eight minutes, 78 of 197 patients (40%)were discharged. If the time to definitive care was eight or more minutes, 44 of 352 patients (13%) were discharged (p<.001). When this study was conducted EMTs could not defibrillate. The study did not define what comprised definitive but discussed the arrival of paramedics and suggested that resuscitation rates might be improved if EMTs could defibrillate. This is the study cited by EMS system designer Jack Stout when he created the 8 minute response time performance requirement back in the early 1980s. Pons PT, Markovchick, VJ, 2002 Eight Minutes or Less: Does the Ambulance Response Time Guidline Impact Trauma Patient Outcome, The Journal of Emregency Medicine Vol. 23, No1, pp. 43-48 This is a retrospective study of 3490 priority 1 trauma patients transported to a single level one trauma center by urban paramedics over a two year period. The patients were placed into two groups, Group I having response times less than or equal to 8 min and group II having a response time greater than 8 min. Survival for the response time groups showed no significant differences weather the patients were evaluated in total or   69

by the subgroups mechanism of injury, patient age, or Injury Severity Score. Their conclusion was, “Exceeding the ambulance industry response time criterion of 8 min does not affect patient survival after traumatic injury. De Maio, Stiell, IG, Wells, GA, Spaite, DW 2003 Optimal Defibrillation Response Intervals for Maximum Out-Of-Hospital Cardiac Arrest Survival Rates Annals of Emergency Medicine 42:2 This prospective cohort study of cardiac etiology out-of-hospital cardiac arrest cases from phases I and II of the Ontario Prehospital Advanced Life Support (OPALS) Study. There were 392 survivors among the 9,273 patients treated. There was a steep decrease in the first 5 minutes of the survival curve, beyond which the slop gradually leveled off. At 9 minutes there were 18 survivors, 8 minutes 0 survivors, 7 minutes 23 survivors, 6 minutes 51 survivors and 5 minutes 86 survivors. In their conclusion they said, “The 8-minute target established in many communities is not supported by our data as the optimal EMS defibrillation response interval for cardiac arrest.” Pons PT, Haukoos JS, Bludworth W, Cribley T, Pons KA, Markovchick VJ 2005 Paramedic Response Time: Does it Affect Patient Survival? Academic Emergency Medicine Jul;12(7):549-600 This was a retrospective cohort study performed in an urban 911-based ambulance service system. Patients transported to a single urban county teaching hospital during 1998 were included. The 9,559 patients transported with data available were categorized into groups based on their level of illness severity. A survival benefit was identified for response times less than or equal to 4 minutes. No survival benefit was identified when response time was modeled as a continuous variable or when dichotomized at 8 minutes. Their conclusion said, “A paramedic response time within 8 minutes was not associated with improved survival to hospital discharge after controlling for several important confounders, including level of illness severity. However a survival benefit was identified when the response time was within 4 minutes for patients with intermediate or high risk of mortality. Adherence to the 8-minute response time

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guideline in most patients who access out-of-hospital emergency services is not supported by these results.”

Blackwell, TH, Kline, JA, Willis, JJ, Hicks, GM 2009 Lack of Association Between Prehsspital Response Tiems and Patient Outcomes Prehsopital Emergency Care 2009;13:444-450 This case-control retrospective study tested the hypothesis that patient outcomes do not differ substantially based on explicitly chosen advanced life support response time upper limit of 10 minutes 59 seconds. This study was conducted in a system with BLS first response followed by ALS transport. There were 373 study patients, Priority 1 transports were response times exceeding 10:59 minutes which, were compared with 373 control patients which were priority 1 calls with response time so of 10:59 or less. Prehospital run reports and hospital outcomes were evaluated focusing on in-hospital death and critical clinical interventions performed in the field. The survival to hospital discharge was 80% for study patients vs. 82% for controls. ALS procedures were performed in 47.7% of the study patients vs. 45.4% of controls. The most frequently performed procedures were the administration of nitroglycerine and endotracheal intubation. They concluded that “Compared with patients who wait 10:59 minutes or less for ALS response, Priority 1 patients who wait longer the 10:59 could experience between a 6% increase and a 4% decrease in mortality and do not have an increase in critical procedures performed in the field.” Bourn S, Stolz, U, Denninghoff, K, Spaite, D 2010 The Relationship between the Rapid Acute Physiology Score (RAPS) and Prehospital Patient Acuity presented at the 2010 National Association of EMS Physicians Annual Conference This retrospective analysis of AMR’s database of 1,222,193 adult EMS patient encounters evaluated the relationship between the Rapid Acute Physiology Score (RAPS) and EMS patient acuity based on the following indicators. •

EMT/Paramedic primary impression of the patient’s criticality



Performance of oral endotracheal intubation



Administration of medications (excluding oxygen)

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Emergent transport to the hospital

This study showed very strong correlation between the RAPS score and patient acuity. For example the likelihood of a patient being intubated increases by nearly twofold with each increase of the RAPS by one. Unpublished analysis of RAPS and response time conducted by Scott Bourn Ph.D. and the AMR Clinical Leadership Team This retrospective study looked at the impact of delayed response times on patient acuity. They evaluated 2 years worth of data from 53 AMR operations in 20 states and included all 911 responses that resulted in transport to the hospital with complete data, N= 269,346. They also looked at ALS First Responder Interventions for 4 operations with ambulance response time standards between 10:30 and 12:30. They evaluated 300,747 non cardiac arrest patient care records that required ALS interventions. IMPACT OF DELAYED RESPONSE TIMES ON PATIENT ACUITY: o Initial and final average patient acuity was calculated using the Rapid Acute Physiology Score (RAPS) for patients grouped by primary impression groups (abdominal problem, altered LOC, behavioral/psych, breathing problems, cardiac/respiratory arrest, cardiovascular, medical problems, OB, pain, sick, toxicology, trauma, and other). o RAPS scores by primary impression were then stratified by ambulance response time within the following groupings (in minutes): < 8, 8-9, 9-10, 1011, 11-12, 12-13, >13. o Patients in cardiac/respiratory arrest appeared to experience an increase in average acuity for response times greater than 11 minutes. This group requires further examination to better understand the relationship and the relative impact of cardiac vs. respiratory arrest. . o There were no identifiable changes in initial RAPS for ANY other group of primary impressions related to response times.

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FIRST RESPONDER INTERVENTIONS: o

ALS interventions by first responders are very uncommon: 

Any ALS intervention: 431/300,747 (0.14% of total sample)



ALS interventions are most commonly required in cardiac arrest: 405/431 (94%)

o

o

Distribution of interventions 

Advanced airway management: 283/431 (66%)



Defibrillation: 190/431 (44%)

Impact of ALS interventions performed in non-cardiac arrest 

There were 26/431 (6%) non-cardiac arrest patients who received first responder intervention. Electronic prehospital medical records were reviewed for all cases.



First responder airway management was successful in 62% of cases



Using the RAPS acuity analysis 12/26 (46%) of patients had an improved condition following first responder intervention

STUDY TYPES: Prospective observational, retrospective case review, scientific literature meta analysis.

POSSIBLE METHODS: Prospective and retrospective comparison of initial RAPS score, survival to discharge, and procedures performed for a convenience sample of Echo and other time sensitive clinical calls grouped by their naturally occurring ALS ambulance response time in Alameda County and other similar EMS systems.

NEXT STEPS: The details of this series of studies including power computations and Institutional Review Board application is proposed to be developed in collaboration with the County EMS Agency’s Medical Director.   73

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Howell, M. D., M. W. Donnino, et al. (2007). "Performance of Severity of Illness Scoring Systems in Emergency Department Patients with Infection." Acad Emerg Med. Objectives To validate the Mortality in Emergency Department Sepsis (MEDS) score, the Confusion, Urea nitrogen, Respiratory rate, Blood pressure, 65 years of age and older (CURB-65) score, and a modified Rapid Emergency Medicine Score (mREMS) in patients with suspected infection. Methods This was a prospective cohort study. Adult patients with clinically suspected infection admitted from December 10, 2003, to September 30, 2004, in an urban emergency department with approximately 50,000 annual visits were eligible. The MEDS and CURB-65 scores were calculated as originally described, but REMS was modified in neurologic scoring because a full Glasgow Coma Scale score was not uniformly available. Discrimination of each score was assessed with the area under the receiver operating characteristics curve (AUC). Results Of 2,132 patients, 3.9% (95% confidence interval [CI] = 3.1% to 4.7%) died. Mortality stratified by the MEDS score was as follows: 0-4 points, 0.4% (95% CI = 0.0 to 0.7%); 5-7 points, 3.3% (95% CI = 1.7% to 4.9%); 8-12 points, 6.6% (95% CI = 4.4% to 8.8%); and >/=13 points, 31.6% (95% CI = 22.4% to 40.8%). Mortality stratified by CURB-65 was as follows: 0 points, 0% (0 of 457 patients); 1 point, 1.6% (95% CI = 0.6% to 2.6%); 2 points, 4.1% (95% CI = 2.3% to 6.0%); 3 points, 4.9% (95% CI = 2.8% to 6.9%); 4 points, 18.1% (95% CI = 11.9% to 24.3%); and 5 points, 28.0% (95% CI = 10.4% to 45.6%). Mortality stratified by the mREMS was as follows: 0-2 points, 0.6% (95% CI = 0 to 1.2%); 3-5 points, 2.0% (95% CI = 0.8% to 3.1%); 6-8 points, 2.3% (95% CI = 1.1% to 3.5%); 9-11 points, 7.1% (95% CI = 4.2% to 10.1%); 12-14 points, 20.0% (95% CI = 12.5% to 27.5%); and >/=15 points, 40.0% (95% CI = 22.5% to 57.5%). The AUCs were 0.85, 0.80, and 0.79 for MEDS, mREMS, and CURB-65, respectively. Conclusions In this large cohort of patients with clinically suspected infection, MEDS, mREMS, and CURB-65 all correlated well with 28-day in-hospital mortality. Goodacre, S., J. Turner, et al. (2006). "Prediction of mortality among emergency medical admissions." Emerg Med J 23(5): 372-5. BACKGROUND: The Rapid Acute Physiology Score (RAPS) and Rapid Emergency Medicine Score (REMS) are risk adjustment methods for emergency medical admissions developed for use in audit, research, and clinical practice. Each predicts in hospital mortality using four (RAPS) or six (REMS) variables that can be easily recorded at presentation. We aimed to evaluate the predictive value of REMS, RAPS, and their constituent variables. METHODS: Age, heart rate, respiratory rate, blood pressure, Glasgow Coma Score (GCS) and oxygen saturation were recorded for 5583 patients who were transported by emergency ambulance, admitted to hospital and then followed up to determine in hospital mortality. The discriminant power of each variable, RAPS, and REMS were compared using the area under the receiver operator characteristic curve (AROCC). Multivariate analysis was used to identify which variables were independent predictors of mortality. RESULTS: REMS (AROCC 0.74; 95% CI 0.70 to 0.78) was superior to RAPS (AROCC 0.64; 95% CI 0.59 to 0.69) as a

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predictor of in hospital mortality. Although all the variables, except blood pressure, were associated with mortality, multivariate analysis showed that only age (odds ratio 1.74, p < 0.001), GCS (2.10, p < 0.001), and oxygen saturation (OR 1.36, p = 0.01) were independent predictors. A combination of age, oxygen saturation, and GCS (AROCC 0.80, 95% CI 0.77 to 0.83) was superior to REMS in our population. CONCLUSION: REMS is a better predictor of mortality in emergency medical admissions than RAPS. Age, GCS, and oxygen saturation appear to be the most useful predictor variables. Inclusion of other variables in risk adjustment scores, particularly blood pressure, may reduce their value. Hargrove, J. and H. B. Nguyen (2005). "Bench-to-bedside review: outcome predictions for critically ill patients in the emergency department." Crit Care 9(4): 376-83. The escalating number of emergency department (ED) visits, length of stay, and hospital overcrowding have been associated with an increasing number of critically ill patients cared for in the ED. Existing physiologic scoring systems have traditionally been used for outcome prediction, clinical research, quality of care analysis, and benchmarking in the intensive care unit (ICU) environment. However, there is limited experience with scoring systems in the ED, while early and aggressive intervention in critically ill patients in the ED is becoming increasingly important. Development and implementation of physiologic scoring systems specific to this setting is potentially useful in the early recognition and prognostication of illness severity. A few existing ICU physiologic scoring systems have been applied in the ED, with some success. Other ED specific scoring systems have been developed for various applications: recognition of patients at risk for infection; prediction of mortality after critical care transport; prediction of in-hospital mortality after admission; assessment of prehospital therapeutic efficacy; screening for severe acute respiratory syndrome; and prediction of pediatric hospital admission. Further efforts at developing unique physiologic assessment methodologies for use in the ED will improve quality of patient care, aid in resource allocation, improve prognostic accuracy, and objectively measure the impact of early intervention in the ED. Olsson, T., A. Terent, et al. (2005). "Charlson Comorbidity Index can add prognostic information to Rapid Emergency Medicine Score as a predictor of long-term mortality." Eur J Emerg Med 12(5): 220-4. OBJECTIVES: To investigate whether co-existing medical disorders, summed up in a comorbidity index, in nonsurgical patients attending the emergency department could predict short-term and long-term mortality, and whether the index could add prognostic information to the Rapid Emergency Medicine Score. METHODS: This was a prospective cohort study. In all, 885 nonsurgical patients, presenting to an adult emergency department and admitted to a medical department of a 1200-bed university hospital during 2 months, were enrolled consecutively. The Rapid Emergency Medicine Score (including blood pressure, oxygen saturation, respiratory rate, pulse rate, age and Glasgow coma scale) was calculated within 20 min in all those admitted to the emergency department. The history of coexisting disorders (Charlson Comorbidity Index)

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was collected from the medical records. RESULTS: In a univariate analysis, the Charlson Comorbidity Index could predict both short-term and long-term mortality in nonsurgical emergency department patients. An increase of one point in the 16-point Charlson Comorbidity Index scale was associated with a hazard ratio of 1.15 (95% CI 1.04-1.28, P<0.0001) for 7-day mortality and 1.28 (95% CI 1.23-1.33, P<0.0001) for 5-year mortality. The Rapid Emergency Medicine Score could also predict both short-term and long-term mortality (hazard ratio for an increase of one point in the 26-point Rapid Emergency Medicine Score scale was 1.33 (95% CI 1.28-1.39, P<0.0001) for 7-day mortality and 1.25 (95% CI 1.22-1.28, P<0.0001) for 5-year mortality. The Charlson Comorbidity Index could also add prognostic information to the Rapid Emergency Medicine Score as a predictor of long-term mortality, but it could not independently predict short-term (3-day, 7-day) mortality when forced into the same multivariate logistic model as the Rapid Emergency Medicine Score (hazard ratio for one point increase in the Charlson Comorbidity Index was 1.20 for 5-year mortality (95% CI 1.15-1.25, P<0.0001). CONCLUSION: Information on coexisting disorders (Charlson Comorbidity Index) can prognosticate both short-term and long-term mortality in the nonsurgical emergency department. It can also add prognostic information to the Rapid Emergency Medicine Score as a predictor of long-term mortality. Olsson, T. (2004). Risk Prediction at the Emergency Department. Medical Sciences. Uppsala, Sweden, Uppsala University: 64. Olsson, T., A. Terent, et al. (2004). "Rapid Emergency Medicine score: a new prognostic tool for in-hospital mortality in nonsurgical emergency department patients." J Intern Med 255(5): 579-87. OBJECTIVES: To evaluate the predictive accuracy of the scoring system Rapid Acute Physiology score (RAPS) in nonsurgical patients attending the emergency department (ED) regarding in-hospital mortality and length of stay in hospital (LOS), and to investigate whether the predictive ability of RAPS could be improved by extending the system. DESIGN: Prospective cohort study. SETTING: An adult ED of a 1200-bed university hospital. SUBJECTS: A total of 12 006 nonsurgical patients presenting to the ED during 12 consecutive months. METHODS: For all entries to the ED, RAPS (including blood pressure, respiratory rate, pulse rate and Glasgow coma scale) was calculated. The RAPS system was extended by including the peripheral oxygen saturation and patient age (Rapid Emergency Medicine score, REMS) and this new score was calculated for each patient. The statistical associations between the two scoring systems and in-hospital mortality as well as LOS in hospital were examined. RESULTS: The REMS was superior to RAPS in predicting in-hospital mortality [area under receiver operating characteristic (ROC) curve 0.852 +/- 0.014 SEM for REMS compared with 0.652 +/- 0.019 for RAPS, P < 0.05]. An increase of 1-point in the 26-point REMS scale was associated with an OR of 1.40 for in-hospital death (95% CI: 1.36-1.45, P < 0.0001). Similar results were obtained in the major patient groups (chest pain, stroke, coma, dyspnoea and diabetes),

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in all age groups and in both sexes. The association between REMS and LOS was modest (r = 0.47, P = 0.0001). CONCLUSIONS: The REMS was a powerful predictor of in-hospital mortality in patients attending the ED over a wide range of common nonsurgical disorders. Olsson, T., A. Terent, et al. (2004). "Rapid Emergency Medicine Score can predict long-term mortality in nonsurgical emergency department patients." Acad Emerg Med 11(10): 1008-13. OBJECTIVES: To examine the Rapid Emergency Medicine Score (REMS) as a predictor of long-term (4.7 years) mortality in the nonsurgical emergency department (ED). METHODS: This was a prospective cohort study. A total of 12,006 nonsurgical patients consecutively presenting to an adult ED at a 1,200-bed university hospital during a period of one year were enrolled. REMS (including blood pressure, respiratory rate, pulse rate, Glasgow Coma Scale score, peripheral oxygen saturation, and patient age) was calculated for all patients admitted to the ED. The statistical associations between REMS and long-term mortality were examined. RESULTS: REMS could predict mortality over 4.7 years (hazard ratio, 1.26; p < 0.0001). Similar results were obtained in the major patient groups (chest pain, stroke, coma, dyspnea, and diabetes). CONCLUSIONS: REMS was a powerful predictor of long-term mortality in patients attending the ED for a wide range of common nonsurgical disorders. Olsson, T. and L. Lind (2003). "Comparison of the rapid emergency medicine score and APACHE II in nonsurgical emergency department patients." Acad Emerg Med 10(10): 1040-8. OBJECTIVES: To improve the Rapid Acute Physiology Score (RAPS) as a predictor of in-hospital mortality in the nonsurgical emergency department (ED) by including age and oxygen saturation, and to compare this new system, Rapid Emergency Medicine Score (REMS), with the Acute Physiology and Chronic Health Examination (APACHE II) with reference to predictive accuracy. METHODS: This was a prospective cohort study. One hundred sixty-two critically ill patients consecutively admitted to the intensive care unit (ICU) during the period of one year, and 865 nonsurgical patients presenting to an adult emergency department (ED) and admitted to a medical department of a 1200-bed university hospital during two months, were enrolled. For all entries to the ED, RAPS was calculated and developed to include noninvasive peripheral oxygen saturation and patient age (REMS), as well as laboratory tests (APACHE II). These scores were calculated for each patient. RESULTS: REMS was found to be superior to RAPS in predicting in-hospital mortality both in the critically ill patients admitted to the ICU and in the total sample (area under receiver-operating characteristic curve [AUC] 0.910 +/- 0.015 for REMS compared with 0.872 +/- 0.022 for RAPS, p < 0.001). An increase of 1 point in the 26-point REMS scale was associated with an odds ratio of 1.40 for in-hospital death (95% confidence interval = 1.36 to 1.45, p < 0.0001). The more advanced APACHE II was not found to be superior to REMS (AUC: 0.901 +/0.015, p = 0.218). CONCLUSIONS: RAPS could be improved as a predictor of

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in-hospital mortality in the nonsurgical ED by including oxygen saturation and patient age to the system. This new scoring system, REMS, had the same predictive accuracy as the well-established, but more complicated, APACHE II. Mackay, C. A., J. Terris, et al. (2001). "Prehospital rapid sequence induction by emergency physicians: is it safe?" Emerg Med J 18(1): 20-4. OBJECTIVES: To determine if there were differences in practice or intubation mishap rate between anaesthetists and accident and emergency physicians performing rapid sequence induction of anaesthesia (RSI) in the prehospital setting. METHODS: All patients who underwent RSI by a Helicopter Emergency Medical Service (HEMS) doctor from 1 May 1997 to 30 April 1999 were studied by retrospective analysis of in-flight run sheets. Intubation mishaps were classified as repeat attempts at intubation, repeat drug administration and failed intubation. RESULTS: RSI was performed on 359 patients by 10 anaesthetists (202 patients) and nine emergency physicians (157 patients). Emergency physicians recorded a larger number of patients as having Cormack and Lehane grade 3 or 4 laryngoscopy than anaesthetists (p<0.0001) but were less likely to use a gum elastic bougie to assist intubation (p=0.024). Patients treated by emergency physicians did not have a significantly different pulse, blood pressure, oxygen saturation or end tidal CO2 to patients treated by anaesthetists at any time after intubation. Emergency physicians were more likely to anaesthetise patients with a Glasgow Coma Score >12 than anaesthetists (p=0.003). There were two failed intubations (1%) in the anaesthetist group and four (2.5%) in the emergency physician group. Repeat attempts at intubation and repeat drug administration occurred in <2% of each group. CONCLUSIONS: RSI performed by emergency physicians was not associated with a significantly higher failure rate or an increased number of intubation mishaps than RSI performed by anaesthetists. Emergency physicians were able to safely administer sedative and neuromuscular blocking drugs in the prehospital situation. It is suggested that emergency physicians can safely perform rapid sequence induction of anaesthesia and intubation. Himmelseher, S., E. Pfenninger, et al. (1994). "[Do we need trauma scoring in emergency medicine?]." Anaesthesist 43(6): 376-84. Trauma scores in emergency medicine quantitatively characterise the severity of trauma victims' injuries and physiologic derangements. They are used to detect and assess patients and have applications in guiding patient care and early therapeutic decisions. In the pre-clinical setting, an effective trauma index meets the following criteria: It is highly reliable with regard to identifying high- and low-risk patients. It has high face-validity. It has high inter- and intra-rater reliability. It is easy to use and allows rapid, accurate measurements. The most widely accepted injury severity index is probably the Injury Severity Score (ISS). It is calculated as the sum of the squares of the three most severely injured body regions, and was originally developed as a means to standardise the description of injuries sustained in motor vehicle accidents. The Trauma Score (TS) represents the gold standard of physiologic scoring of injury severity. It

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summarises the numerical assessments of the central nervous and cardiopulmonary system functions. The recently developed Mainz Emergency Evaluation Score (MEES) is based upon numerical specification of the vital signs, including a pain scale, and has been designed as a dynamic score. Nevertheless, limitations of the established trauma score systems have been described. Mortality and patient outcome do not strictly correlate with injury severity scoring. In addition, intubated or paralysed patients were excluded from outcome studies since the scoring systems lacked options for evaluation of pathophysiological conditions after therapeutic interventions. Thus, therapeutic efficacy could hardly be assessed, and subsequent scoring during time periods was impossible.(ABSTRACT TRUNCATED AT 250 WORDS) Schuster, H. P. and W. Dick (1994). "[Scoring systems in emergency medicine?]." Anaesthesist 43(1): 30-5. The primary goals of scoring in emergency medicine are grading of the severity of the patient's condition, measurement of diagnostic and therapeutic efforts, forecasting the outcome, and support in decision making on triage and therapy. Scores can also be used as tools for measuring efficacy and controlling quality. There has been less experience with use of scoring systems to estimate quality of life. The ability to make a prognosis in an individual case is the most critical point; a score may support decisions on therapy in very specific situations only. Scores for use in emergency medicine should be based on physiological parameters, universally applicable and suitable for use throughout the course of diseases. Appropriate score systems are the Glasgow Coma Scale, the Rapid Acute Physiology Score, and the Mainz Emergency Evaluation Score, Trauma Score and Injury Severity Score. Scores suitable for estimation of quality of life following emergencies are the Glasgow Outcome Scale and the Glasgow-Pittsburgh Scale. Bein, T. and K. Taeger (1993). "[Score systems in emergency medicine]." Anasthesiol Intensivmed Notfallmed Schmerzther 28(4): 222-7. Trauma scores are used in emergency medicine to classify the severity of injuries. Score systems are applied in science and epidemiological investigations in emergency and intensive care. Moreover, trauma scores are intended to support the decisions in triage and predict the prognosis of mortality. Scores are based on anatomicmorphological or physiological parameters by which the intensity of injury is graded and valued. Commonly used scores are the Injury Severity Score (ISS) and the Revised Trauma Score (RTS). The Glasgow Coma Scale (GCS) is a system that is used worldwide to classify neurologic deficiencies after injury of the brain. Trauma scores have a good prognostic potential by comparing large data bases of different patient groups. Individual prognosis of mortality by trauma scores in the routine of emergency medicine are rapid classification of the injury after trauma and early identification of critically ill patients. Score systems can support decisions and the training of emergency staff. Future studies should go into the grade of rehabilitation and the quality of life after trauma as a -possibly score-aided-prognostic parameter.

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Hennes, H. J., T. Reinhardt, et al. (1993). "[The preclinical efficacy of emergency care. A prospective study]." Anaesthesist 42(7): 455-61. Quality assurance has become an important issue in emergency medicine. At present, no prospective studies are available that quantify the efficacy of interventions performed by emergency doctors. The development and implementation of a rapid, yet simple scoring system, allowing preclinical assessment of all emergency medicine patients, is required. Once the scoring system is implemented, evaluation of the prehospital intervention, based upon objective parameters, is possible. METHODS. The Mainz Emergency Evaluation Score (MEES) is based on seven parameters: level of consciousness, heart rate, heart rhythm, arterial blood pressure, respiratory rate, partial arterial oxygen saturation and pain. A coded value is assigned to each parameter, with the normal physiological condition securing a score of 4, while a life-threatening condition receives a value of 1. For the parameter of pain there is no life-threatening condition, so the lowest value allowed is 2 (Table 2). Addition of the respective values from the seven parameters yields the MEES value, which objectively reflects the patients' condition (minimum = 8, maximum = 28). Comparing the MEES value before (MEES1) and after the intervention (MEES2) allows an objective evaluation of the efficacy of the preclinical care (delta-MEES = MEES2-MEES1). A difference of > or = +2 is considered an improvement, +1, +/- 0, -1 are rated as unchanged and < or = -2 is considered a deterioration in the patients condition. For more detailed evaluation the patients were allocated to 16 diagnosis groups (Table 3). Statistical evaluation utilized analysis of variance, the rank sum test (Wilcoxon) and the correlation coefficient (Kendall-Tau). RESULTS. In 356 patients the condition of 187 (52%) patients improved during the preclinical treatment; the condition of 156 (44%) patients did not change. In 13 patients (3%) the condition became worse (Table 5, Fig. 2). Allocation to 16 diagnosis groups revealed that the improvement in the patient's condition depended on the underlying disease (Table 3); the disease-specific parameter improved in all cases (Table 7). CONCLUSIONS. With the MEES score one can assess the patient's prehospital condition and monitor any improvement or deterioration during subsequent intervention and transport. The MEES was found to be easy to use, reliable and not an additional burden to emergency doctors. The MEES provides a means of assessing the efficacy of preclinical treatment. This score does not allow outcome prediction; this requires the inclusion of hospital data. Assessment of the efficacy of prehospital intervention is an important first step in the inclusion of quality assurance in emergency medical systems. Rhee, K. J., W. G. Baxt, et al. (1990). "Differences in air ambulance patient mix demonstrated by physiologic scoring." Ann Emerg Med 19(5): 552-6. Severity of illness or injury should be the primary justification for aeromedical transport. To determine whether differences in patient severity were detectable in air transport programs, helicopter-transported patients were examined by three established physiologic scores: the Trauma Score, the Acute Physiology

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and Chronic Health Evaluation Score, and the Rapid Acute Physiology Score. These scores were obtained prospectively on 1,868 consecutive patient transfer requests from six air medical services for periods ranging from two to six months. A patient meeting strict physiologic criteria was considered critically ill. Overall, 42.6% of the patients (range, 34.8% to 53.3%) were considered critically ill. Patients transported from inpatient hospital units and patients with cardiac disease were less likely to be critically ill than those transported emergently from scenes of accident or from emergency departments. There were also significant differences between programs with regard to the percentage of critically ill patients transported. This study suggests that physiologic scoring may be useful in comparing air ambulance programs and that a majority of patients transported by these services may not be critically ill. Rhee, K. J., J. R. Mackenzie, et al. (1990). "Rapid acute physiology scoring in transport systems." Crit Care Med 18(10): 1119-23. A multi-institutional study was undertaken to define the predictive power for mortality of the Rapid Acute Physiology Score (RAPS) in a large and diverse group of transported patients. RAPS is a truncated version of the Acute Physiology and Chronic Health Evaluation (APACHE II) score that uses definitions and weighting consistent with APACHE II, but is modified to provide a consistent score just before transport, just after transport, and to use the most deranged (worst) physiologic values during the initial 4 h after arrival at the receiving hospital. During an 8-month period, 1,927 patients transported by six helicopter emergency medical service programs were studied. Over 97% (1,881) of the patients had RAPS obtained before and after transport to the receiving hospital and 92.6% (1,785) had APACHE II scoring completed after hospital admission. Receiver operating curves demonstrate similar predictive power for RAPS and APACHE II (both based on the most deranged physiologic values during the initial 24 h after admission). Before- and after-transport RAPS were also highly predictive of mortality. RAPS appears to be a reliable and highly predictive measure of patient severity/physiologic stability before and after transport to critical care. Rhee, K. J., C. J. Fisher, Jr., et al. (1987). "The Rapid Acute Physiology Score." Am J Emerg Med 5(4): 278-82. The Rapid Acute Physiology Score (RAPS) was developed and tested for use as a severity scale in critical care transports. RAPS is an abbreviated version of the Acute Physiology and Chronic Health Evaluation (APACHE-II) using only parameters routinely available on all transported patients (i.e. pulse, blood pressure, respiratory rate, and Glasgow Coma Scale). RAPS has a range from 0 (normal) to 16. Two hundred eighty-three patients were transported by helicopter; 62 died. Pretransport RAPS was available on 282 of 283 patients (mean, 3.85; median, 3). Because of death, discharge, or transfer, 227 complete APACHE-II scores using least physiologic values for the first 24 hours after transfer were collected (mean, 14.98; median, 13). Stepwise logistic regression showed that when all APACHE-II and RAPS values were available, the best

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single predictor of mortality was worst value APACHE-II (X2(1) = 57.09, P less than .01). When pretransport RAPS was considered as a single explanatory variable, it too had significant predictive power for mortality (X2(1) = 92.53, P less than .01). Correlation analysis comparing RAPS with APACHE-II values at similar points in time revealed a significant relationship in all cases, with the highest correlation between RAPS worst values and APACHE-II worst values (r = .8472, P less than .01). It was concluded that RAPS can be applied usefully in complement with APACHE-II and may have limited utility when used alone. Copass, M. K., M. R. Oreskovich, et al. (1984). "Prehospital cardiopulmonary resuscitation of the critically injured patient." Am J Surg 148(1): 20-6. Prehospital cardiopulmonary resuscitation combined with endotracheal intubation, vigorous fluid resuscitation, and rapid transport can be effective in resuscitating trauma patients in cardiopulmonary arrest. Survival does not correlate with the injury severity score or transport time once the patient has arrested but does correlate with the mechanism of injury, endotracheal intubation, and placement of intravenous lines.

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2010 Baldrige Self-Analysis Worksheet While insights gained from external Examiners or reviewers are always helpful, you know your organization better than they will. You are currently in an excellent position to identify your organization’s key strengths and key opportunities for improvement (OFIs). Having just completed your responses to the Baldrige Criteria questions, you can accelerate your improvement journey by doing a self-analysis of your responses to all seven Criteria Categories using this worksheet. Start by identifying one or two strengths and one or two OFIs for each Criteria category. For those of high importance, establish a goal and a plan of action.

Criteria Category

Importance High, Medium, Low

For High-Importance Areas Stretch (Strength) or Improvement (OFI) Goal

What Action Is Planned?

By When?

Who Is Responsible?

Category 1—Leadership Strength 1. Shared Purpose and Vision

High

Development of measurement system that fully aligns with Purpose and Vision.

Present concept to Quality Leadership Team seeking approval for development.

03-11-10

Diane Akers

2. Shared Values

High

Development of midmanagement Users Guide to assist with value judgements and actions.

Identify Quality Leadership Team Member to serve as “steward” of the development of the Users Guide.

03-11-10

Mike Taigman

Completion of group Core DDI Training courses by all operational leaders.

Schedule Core CCI Training Sessions for operational leadership group.

04-30-10

Mike Taigman

High

Alameda County AMR’s Strategic Objectives aligned with System Partner’s for system-wide execution.

Convene collaborative system-wide stakeholder workshop to develop shared strategic objectives.

02-28-10

Mike Taigman

High

Alameda County AMR’s Strategic Objectives aligned with Community’s initiatives for community wide implementation.

Work with the Ethnic Health Institute in the development of a strategic planning retreat with Community stakeholders.

09-30-10

Tricia Frachetti

OFI 1. Succesion Planning Process 2. Day-to-Day Leadership Styles

Medium

High

Category 2—Strategic Planning Strength 1. Corporate Support 2. Execution of Strategic Objectives

Medium

OFI 1. Community Involvement

2009–2010 Education Criteria for Performance Excellence 83

Criteria Category 2. Customer Involvement

Importance High, Medium, Low High

For High-Importance Areas Stretch (Strength) or Improvement (OFI) Goal

What Action Is Planned?

By When?

Who Is Responsible?

Analysis of Customer Satisfaction Survey.

Complete detailed analysis of Customer Satisfaction Survey matrixes and feedback.

03-15-10

Scott Salter

Category 3—Customer Focus Strength 1. Feedback Process for Regulatory Customers

High

Feedback process extended from EMS Agency to include parent Alameda County Health Services.

Support creation of System Wide Advisory Board.

04-30-10

Mike Taigman

2. Two Dedicated Customer Service Representative

High

Maintain existing and grow new customer relationships.

Execution of Alameda County AMR Operational Growth and Customer Retention Plan.

01-01-10

Daiann Antony Steve Martin

OFI 1. Customer Satisfaction Survey Follow-up

High

Developed system which provides timely documented follow-up as well as prospective and retrospective review for learning opportunities.

Convene meeting to discuss concept and process for development of prospective and retrospective review system.

02-28-10

Lee Siegel

2. Live Customer Feedback for All Customers

High

Customers that are verbally challenged will have a mechanism to communicate and receive feedback on customer service issues.

Meet with Alameda County Access Group to explore concept and solutions.

04-30-10

Lauri McFadden

Category 4—Measurement, Analysis, and Knowledge Management Strength 1. Data Collection

Medium

2. Team Trained in Statistical Process Control

Medium

OFI 1. Understanding of data relevance

High

Alameda County leaders define relevant data as it relates to system performance and patient outcomes.

Alameda County leaders to review measured data elements for level of importance.

06-30-10

Mike Taigman

2. Data Set Composite Scores

High

First Watch and first responder bio-key data connected.

Alameda County leaders and First Watch agree on terms. Alameda County AMR provides financial support for bio-key data connection.

01-31-10

Lee Siegel

2009–2010 Education Criteria for Performance Excellence 84

Criteria Category

Importance High, Medium, Low

For High-Importance Areas Stretch (Strength) or Improvement (OFI) Goal

What Action Is Planned?

By When?

Who Is Responsible?

Category 5—Workforce Focus Strength 1. Open Collaborative Dialogue

High

All operational leaders conduct face-to-face interaction with front-line employees to ensure each employee is met with on a monthly basis.

Monthly follow-up between Operations Manager and Operations Supervisors to ensure face-to-face interactions have occurred.

Monthly

Lauri McFadden

2. Employee Survey system

High

Support system and shorten timeframe from survey to employee feedback.

Empower Operations Supervisors to provide feedback in monthly faceto-face frontline meetings.

01-31-10

Greg Freese

High

Optima Software Suite implemented.

Complete training of dispatch personnel and operational leadership team.

01-31-10

David Lindberg

1. Vehicle MakeReady Process

High

Consistently provide fully-stocked and clean ambulances at front-line staff shift change.

Review vehicle makeready process of those operations that set the benchmark for industry.

01-31-10

Leslie Simmons

2. Documenting Schedule and Lost Unit Hours

Medium

Improve “pain, shortness of breath, discomfort” customer satisfaction score by 5%.

Develop matrix analysis of current results and compare treatment provided to protocol.

01-31-10

Scott Salter

OFI 1. Union Relationship

Medium

2. Communication w/remote employees

Medium

Category 6—Process Management Strength 1.Understand Process Design 2. Highly Refined Process for Producing Response Times

Medium

OFI

Category 7—Results Strength 1. Customer Satisfaction

High

2009–2010 Education Criteria for Performance Excellence 85

Criteria Category

Importance High, Medium, Low

For High-Importance Areas Stretch (Strength) or Improvement (OFI) Goal

What Action Is Planned?

By When?

High

Additional composite indicators developed for STEMI, stroke, cardiac arrest, pain management and unconsciousness.

Gather evidence and research materials/abstracts for all categories.

01-31-10

Elsie Kussel

1. Financial Results

High

Reduce lost inventory and unit hours.

Understand current categorial losses for baseline.

01-01-10

Lauri Mcfadden

2. Composite Airway Checks

High

Improve composite airway checks 20%.

Design mechanism to provide system-wide performance feedback to all system participants.

03-01-10

Patrick Lickiss

2. Clinical Results

Who Is Responsible?

OFI

2009–2010 Education Criteria for Performance Excellence 86

Clinical Summary of Clinical/Service Inquiries and Resolutions

87

88

Operational Calls and Transports by Priority, Emergency Response Zone and sub area.

89

Operational A list of each and every call, sorted by Emergency Response Zone where there was a failure to properly record all times necessary to determine the response time; and for patients meeting trauma criteria, on-scene time and/or transport to hospital time.

Operational A list of mutual aid responses to and from system.

90

Operational Copies of any memos distributed to field personnel related to EMS clinical or system issues.

91

Operational Canceled transports.

Operational Exception reports and resolution.

92

Operational Penalties and exemptions. Alameda County Response Time Compliance Summary For the month of December, 2009

North

South

East

Total

Total Requests

4,501

3,882

826

9,209

On-time

4,094

3,535

758

8,387

407

347

68

822

90.96%

91.06%

91.77%

91.07%

Requested

3

1

0

4

Granted

3

1

0

4

404

346

68

818

91.02%

91.09%

91.77%

91.12%

$4,000.00

$4,000.00

$4,000.00

$12,000.00

$0.00

$0.00

$0.00

$0.00

Late Raw Compliance Exemptions

Adjusted Late Calls Adjusted Compliance Penalty Compliance Penalty Extended Response Unauthorized BLS Total Penalty

Response Time Compliance A list of each and every emergency call dispatched for which the Contractor did not meet the response time standard, and reported by each Emergency Response Zone and sub-area.

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Response Time Statistical Data Within 10 working days following the last day of each month, Contractor and County EMS shall receive ambulance response time records from the County Dispatch Center (s) in a computer readable format approved by the EMS Director and suitable for statistical analysis for all ambulance responses originating from requests to the County's PSAP centers. These records shall include the following data elements: Unit Identifier Longitude/Latitude Code to Scene Time unit enroute Time unit at hospital Outcome Major Trauma

Street Address County/Unincorporated Area ERZ/sub-area EMD Code Time call received Time call dispatched Time unit on-scene Time enroute to hospital Time unit clear and available for next call Receiving Hospital Code to hospital Number of patients transported

94

Personnel Reports List of EMTs and Paramedics.

Community Governmental Affairs Report Events Conducted Alameda County Public Information and Education December 2009

Date 12/5/09

Event Safety Fair

City N/A

Description/Hours BLS/5.0

12/7/09

CPR Class Training/CRECE

N/A

ALS/2.0

12/7/09

EMT Demo w/James Monroe Elementary

N/A

ALS/1.0

12/8/09

EMT Demo w/James Monroe Elementary

N/A

ALS/1.0

12/9/09

EMT Demo w/James Monroe Elementary

N/A

ALS/1.0

12/10/09

EMT Demo w/James Monroe Elementary

N/A

ALS/1.0

12/11/09

Tree Planting Event

N/A

ALS/4.0

12/11/09

Tree Planting Event

N/A

BLS/8.0

12/11/09

Kaiser MRI Training Event

N/A

BLS/5.0

12/12/09

Alameda County Flu Clinic

N/A

ALS/15.0

12/12/09

Alameda County Flu Clinic

N/A

BLS/15.0

12/31/09

New Years Eve Bart Stand By

N/A

ALS/4.0

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EnRoute Ambulance CAD The EnRoute Ambulance CAD system quickly and efficiently dispatches appropriate units with critical information needed to properly handle any situation. It provides the tools to help WIN THE RACE AGAINST TIME.

The Status Bar provides a snapshot of the current system status, using icons and text to alert the dispatcher to new messages and new memos from other CAD users.

Overview

 Standard operating procedure screens can be tied to call type or location

Immediate response, safety, better decision-making, and reliability depend on the timely and secure communication of accurate information. Available on Unix and Window servers, the EnRoute Ambulance Computer-aided Dispatch (CAD) products are specifically designed to facilitate quick response to incoming calls, rapid dispatch of required units, and complete documentation of incidents. The CAD application is designed to assist the dispatchers with up-to-the second system status displays, summarizing the calls being worked, unit assignments, and real-time demand analysis. Color-coded system status information and message alerts provide high-visibility information summaries. Statuses are coded to match the unit status colors elsewhere in the system for cross-referencing. Dispatchers can select displays or CAD functions using the mouse or by entering simple commands at the Status Bar. Status displays are configurable for each dispatcher with administrative overrides.

Key Features

 Count down and contract timers  Unit and call equipment requirements  Unit recommendation by type for given situations and areas  Response time parameters by area  Medical information  Drag-and-drop call scheduling and dispatching  Command line entry on key commands for quick formless updates  Call morphing for return trips  Caution flags  Customizable new call and summary screens  Hospital divert  Optional mapping into new call entry and active call details screens  Interactive calendar client scheduling  Prior call and unit history  Trip schedules can be displayed based on times or pre-assigned units for zones and/or vehicle type

User-definable placement of multiple menus provides each calltaker or dispatcher with maximum flexibility to utilize own layout preferences.

 Use of different colors and symbols to differentiate call status and priorities

WIN THE RACE AGAINST TIME ®

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Integration Options

Dynamic New Call Entry Screens

EnRoute Ambulance CAD systems are fully integrated to provide interfaces with other records and CAD systems, E911 inbound systems, AVL, a range of mapping solutions, Priority Dispatch Corporation’s ProQA software, Bradshaw Consulting Services’ MARVLIS System Status and Demand Monitoring, mobile data computers, alphanumeric paging, and interfaces between billing systems, etc.

You may design your own New Call entry screens. Based upon certain field values, additional screens may be displayed for associated details. A default emergency and non-emergency screen can be set up and accessed with standard command prompts. New Call entry screens set up for specialized use are accessed with command prompts defined by your administrator. A calltaker may switch between emergency and nonemergency calls in the middle of a call if the priority or nature of the call changes, morphing data from original screen into the new format.

Key Benefits  Simplifies and accelerates response to emergency or time-critical situations.  Places critical, time-sensitive information directly into hands of field personnel. Trip schedules can be displayed based on times or pre-assigned units for zones and/or vehicle type.

 Allows graphical display forms, status keys, and inquiry forms to be completely customized (site-specific).  Aids in personnel safety and awareness by keeping all participating units informed.  Maximizes personnel and productivity by providing intelligent unit recommendations based on resources, skill requirements, priority, call nature, location, historic data, and/or special equipment requirements.  Eliminates redundant data entry between integrated systems.  Permits security to be set up at various levels to allow personnel to take control without sacrificing data integrity.

Workloads and daily totals can be displayed by unit for emergency calls, nonemergency calls, transports, patients transported, calls per hour, transports per hour, and total time worked.

Main: Sales: Fax: E-mail: Web:

 Promotes customer service by enabling design of calltaker forms to meet priority client specifications.

(813) 207-6911 (813) 207-6951 (678) 393-5395 [email protected] www.enroute911.com

Copyright © 2008 Infor. All rights reserved. The word and design marks set forth herein are trademarks and/or registered trademarks of Infor and/or related affiliates and subsidiaries. This data sheet is for informational purposes only. All rights reserved. The IBM logo and the IBM Premier Business partner emblem are trademarks of International Business Machines Corporation in the United States, other countries, or both. Microsoft is a registered trademark of Microsoft Corporation in the United States and/or other countries. All other trademarks listed herein are the property of their respective owners. 97www.infor.com.

live

Live By using advanced mathematical based technology we fuse your organizations staff, transport and the community’s requirements together to enable them to work as one. We provide both accurate ‘real time’ and ‘long term’ strategic recommendations that enable organizations to operate at a higher level of efficiency, make better decisions and face fewer challenges

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OPTIMIZE DEPLOYMENT AND IMPROVE PERFORMANCE WITH ENHANCED REAL-TIME EMERGENCY SERVICES DECISION SUPPORT.

The right place. The right time. Everytime. For an emergency services system to maximize its performance and make the best use of its resources, there is nothing more important than ongoing vehicle coverage and accurate deployment to support intelligent dispatch decisions. tm

Optima live is Optima’s world leading suite of real time dynamic deployment solutions that incorporate predictive analytics to assist dispatchers with emerging coverage challenges, while at the same time making optimized recommendations for unit deployment.

Optima live provides real-time decision support for emergency services in an easy-to-use graphical interface. It is run entirely from the communications center providing information and accurate recommendations to dispatchers and supervisors to assist with the important deployment decisions confronting communications staff. tm

To deploy vehicles effectively, staff need to know more than just what’s happening now, they also need to know what is likely to happen next. That is why Optima live provides ‘Look Ahead Technology’, the next generation of real time decision support. tm

The suite of Optima live products takes into account current and historical call volume for the day of the week and time of day and then uses sophisticated predictive analytics that can forecast changes in the system over the critical next 20 minutes. Optima live monitors the status of resources and continually optimizes to find the best possible solutions. It is able to provide the communications center with realistic deployment recommendations for the best possible coverage, minimizing unnecessary moves that tax crews or waste fuel. tm

tm

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The Optima live products provide state-of-the-art features customized for the center, including: • A highly tuned road network to provide realistic travel times for all vehicle movements (lights-andsirens and normal responses), calibrated specially for the service using actual vehicle and call information • Differentiated coverage tiers based on vehicle capabilities (first response or transport, advanced life support, etc.) • Specific deployment recommendations in real time based on advanced mathematical optimization techniques, with the corresponding improvement in coverage displayed in a quantifiable format • Highly configurable displays, with the ability to customize colors and icons to match the dispatch service’s existing visuals • Predictive analytic algorithms based on the proven scientific approach of Operations Research tm

Optima live real time view is the foundation platform that receives, processes and displays real time data from the computer aided dispatch (CAD) system. Optima live real time view provides the application framework for the other Optima live products as well as including the data visualization components and configuration. tm

tm

• Optima live post plan manager that provides a real time view of the post plan compliance allowing dispatchers to maintain conformity to agreed geographic or demand-driven deployment tm

tm

Optima’s intelligent decision support is further enhanced by the products that leverage the Optima live real time view platform. These are: • Optima live dispatch that provides dispatch recommendations based on highly configurable logic thus improving both the speed and accuracy of dispatch • Optima live deployment that provides deployment recommendations, improving the level of coverage provided by the current and soon to be available vehicles in order to improve overall response time compliance tm

tm

In addition to these products, Optima live deployment includes a number of additional plug-ins that further enhance the functionality available for real time decision support. These include: • Meal Monitor to track meal breaks assigned to each unit • Shift Manager to manage planned shifts and match these to active shifts tm

tm

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HOW DOES IT WORK? ROAD NETWORK The Road Network is one of the core underlying technologies in Optima live . The road network is used to perform all the drive-time calculations necessary to calculate coverage and is used for both Deployment and Dispatch decision support. tm

The Road Network is tuned by means of historical vehicle travel information. Optima uses historic incident and AVL data to calculate realistic drive-times for each road segment in the model. These drive-times are time sensitive, capturing the difference for instance between Monday morning and Sunday afternoon REAL TIME WINDOW The Real Time Window is the primary graphical interface through which the user interacts with Optima live products. It provides a map display and allows the user to see the current state of the system, consisting of the display elements as listed alongside. By showing these elements on a map, the user can quickly appraise the current state of the system.

tm

THE VEHICLE LIST The vehicle list shows all vehicles currently active in Optima live , along with the information about those vehicles. The vehicle list is displayed underneath the map display windows. tm

CALL HOTSPOTS Call Hotspots provide an estimate of how busy a particular area is likely to be. Optima live uses historic call data to calculate Call Hotspots for each hour of the day and day of the week. These are based on configured rules to account for call growth and expected changes in call patterns. These rules are used to dynamically calculate the call hotspots using several years of historic data and the hotspots are updated as new call data is received. tm

REAL TIME WINDOW

ROAD NETWORK

tm

The following elements can be displayed in Optima live : • Road Network • Vehicle type and location • Vehicle coverage • Call hotspots • Location of stations, posts & hospitals

VEHICLE LIST

The Optima livetm real time view platform for the suite of Optima livetm products is built up as follows:

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tm

Coverage depth refers to the number of vehicles that cover a location. Optima live uses the tuned road network to provide realistic coverage estimates that account for time of day and day of week variations. Coverage is indicated by the blue shading and darker blue indicates greater coverage depth.

CALL HOTSPOTS

tm

tm

Playback functionality provides a number of very powerful benefits: • Playback can be used to investigate incidents by providing an immediate reconstruction at any given point in time • The reconstruction immediately shows the location and status of every active vehicle on the graphical map display • The images from the reconstruction can be captured and included in incident reports

TM

KEY BENEFITS OF OPTIMA LIVE REAL TIME VIEW Optima live Real Time View is primarily the enabling technology for the suite of Optima live products. However, in its own right, Optima live real time view provides some distinct benefits: • Powerful display gives users up to date visual status information • The tuned road network provides an accurate up to date coverage display • Call hotspots show historic demand patterns specific to the time of day, day of week and day of the year • Configurable to user requirements, with familiar color codes and display icons tm

tm

tm

PLAYBACK

DISPLAY COVERAGE Optima live calculates coverage and coverage depth based on the current state of the system. A location is covered if an available vehicle can reach that location in the specified response time. This is not just pure drive time but includes other factors that can significantly affect the total response time such as known mobilization delays.

PLAYBACK Optima live records the data it receives from the CAD system, allowing a user with appropriate access to review and replay situations as needed. This allows: • Detailed reviews of events, allowing investigation and evaluation of performance including manual and optimized deployments and dispatch decisions • Flexible control of playback, including controlling the speed of playback and going directly to a specified time, allowing the user to focus on critical events

DISPLAY COVERAGE

The configuration allows the specification and management of special occasions. These are times where the call arrival rate is known to be atypical and should be treated differently. Common examples include major holidays, such as Christmas and New Year, or major events.

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OPTIMA LIVE DISPATCH TM

What would you do to reduce response times dramatically? Managing communication centers for emergency services is an incredibly complex task. Dispatchers deal with hundreds of thousands of decision making permutations in their heads while in reality the challenges presented by juggling vast amounts of spatial and temporal information are difficult for the human mind to adequately manage. Optima live dispatch involves managing the complex interdependencies of your business in a time critical environment to ensure that you have the right information at your fingertips to make the best decision there and then, time after time after time. tm

What does Optima live dispatch do? Optima live dispatch is a solution that can substantially improve the speed and accuracy for a dispatcher to make reliable assignment decisions. The underlying mathematics of the software incorporates relevant business rules while considering all of the variables that might impact a dispatch decision and instantly delivers the right solution to the dispatcher in a visually rich way. This significantly reduces the “vehicle assign” component in the dispatch process delivering valuable time savings at the front end of the response process. tm

tm

How it works Using Optima’s Operations Research expertise, Optima live dispatch has a foundation of sophisticated mathematics that considers the following factors during its calculations: • Current road speeds • Time of day sensitivity • Location of all available vehicles – including those that are en-route to another call • Lights & sirens travel speed • Available vehicle types • ALS & BLS teams tm

• Category of the call • Response time compliance • Predefined business rules All of these factors are continuously recalculated in ‘real-time’ to ensure the recommendations provided to the dispatchers are accurate, and support all operational business rules. The recommendations are instantaneous, and, providing the dispatcher is comfortable with these, they are only a mouse click away from dispatching the chosen vehicles via the computer aided dispatch (CAD) system. Optima live dispatch will also provide immediate alternative options to support the dispatcher’s decision making process. tm

Key benefits of Optima live dispatch are: • Significant reduction in total response time • Prevention of dropped calls • Knowing that the closest unit is always assigned to the highest priority incidents tm

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tm

The first view is the Real Time View; in this window the users can see all vehicles across the network, the vehicles’ current status, call coverage and areas of anticipated high call demand. The second view is the dispatch window; here users can see all calls waiting for dispatch.The dispatcher simply chooses a call by selecting it for assignment. Optima live dispatch will then automatically provide a dispatch recommendation that is based on the predefined logic and current workload.

tm

Optima live dispatch also provides immediate alternative recommendations should the dispatcher need to consider other options. tm

Clicking on the Confirm button pushes the recommended move back to CAD and the vehicles are immediately assigned to the call.

REAL TIME WINDOW

tm

Optima live dispatch highlights the best combination of resources to dispatch for the incident type, factoring in their expected time of arrival. The vehicle(s) are identified in the Real Time View window.

DISPATCH WINDOW

Twin interface The Optima live dispatch interface provides the emergency communicator with two views of the live situation.

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OPTIMA LIVE DEPLOYMENT TM

Imagine being able to accurately improve your service coverage twenty minutes into the future. Optima live deployment improves your service coverage and response times by delivering proactive recommendations to your communications center regarding the best possible vehicle deployments. Using built-in intelligence, Optima live deployment automatically accounts for key performance indicators such as response time compliance and vehicle coverage, then displays all recommendations on an easy-to-use interface, allowing users to make accurate and immediate deployment decisions. tm

tm

Optima’s real time dynamic deployment solutions incorporate predictive analytics to assist dispatchers with emerging coverage challenges, while at the same time making optimized recommendations for unit deployment.

tm

What does Optima live deployment do? Optima live deployment leverages Optima’s extensive Operations Research expertise and uses sophisticated mathematics to determine the best locations to deploy the available vehicles. Based on historical call demand and “Look Ahead Technology”, Optima live deployment’s visually rich interface illustrates the future situation and then recommends the best possible moves to achieve maximum coverage. tm

tm

How it works Optima live deployment applies mathematical models to real-time data to present users with accurate deployment recommendations. How it does this can be described in three parts. tm

Firstly, in real time it considers all influencing variables such as real time road speeds, the time of day, directional differences, and lights and sirens vs non lights and sirens speeds when making a recommendation.

required response times and it uses AVL plus Computer Aided Dispatch (CAD) data to determine the exact location and status of every vehicle. Thirdly, it captures the complex business rules and reviews all of the service’s historical incident patterns to estimate the status and location of vehicles in the near future. This is called “look-ahead technology”. Additional information considered in this process includes knowledge of vehicles about to start or finish shifts, clear scenes or hospitals, or embark on meal breaks. All of these human factors are blended with the business rules and fed to the optimizer, which provides accurate deployment recommendations to the communications center.

Key benefits of Optima live deployment are: • Intelligent support to dispatchers • Accurate view of future coverage • Consistent logical recommendations You cannot change what is happening for deployments now, but with Optima live deployment Secondly, it is programmed to recognize • No unnecessary deployment moves you can influence what will happen in all historical call hotspots, vehicle types, • Automated management of meal the near future breaks and shift changes • Improved coverage – where it is required tm

tm

105

MEAL MONITOR The Meal Monitor provides users with information about meal breaks, improving the ability of the service to achieve meal breaks and reduce the costs associated with missed meal breaks. In addition, the meal status can be used by other Optima live products. tm

tm

Optima live deployment can apply special rules for the status, such as ensuring that a vehicle due its meal break is deployed to an appropriate location to take the meal break. Optima live dispatch considers meal status in making dispatch decisions, such as not considering a vehicle due a meal break for response to a low priority incident.

SHIFT MANAGER Shift Manager correctly matches active shifts to pending shifts. This allows Optima live deployment to provide look-ahead modeling of shifts starting and finishing and to provide any end of shift rules. tm

tm

Optima live dispatch can use the time until end of shift when making dispatch recommendations, such as excluding vehicles due to finish their shift from responding to a low priority call.

tm

LOOK AHEAD The first is the look-ahead mode which is shown in a split-screen, with the real-time window on the left (current status) and the look-ahead display on the right (how the coverage will look in the future). This provides the user with a quick view of how the situation will change.

DEPLOYMENT The second user interface view illustrates the Deployment mode and shows the look-ahead display on the left and the deployment display on the right. In Deployment mode the user can preview the impact of both manual and automatic deployment moves.

Look ahead uses configurable business rules to estimate how the current situation will change in the next 20 minutes and then provides a coverage plot based on this estimate which is illustrated in the right hand view. The look-ahead rules account for: • Vehicles starting and ending shifts • Meal breaks • Vehicles clearing from calls and returning to their base • Realistic drive-times for vehicles on calls, driving to a deployment post, or returning to base

Deployment uses historic call patterns to prioritize where vehicles should be moved. The recommended moves are constrained by highly configurable business rules and include options such as: • Keeping vehicles near their home station • Returning vehicles home at the end of their shift and for meal breaks • Use different rules for single response cars rather than ambulances or any other specialized resource type

DEPLOYMENT WINDOW

LOOK AHEAD WINDOW

The Interface There are two user interface views seen by the communications centre.

106

OPTIMA LIVE POST PLAN MANAGER TM

Optima live post plan manager provides a Real Time view of your Post Plan compliance. Consistently managing a coverage plan in real time is a complex and challenging task for dispatchers. Their ability to visualize a coverage plan in their minds to ensure comprehensive real-time compliance is limited and the resulting costs of not doing so can be significant to response time performance and any non compliance penalties. tm

What does Optima live post plan manager do? Leveraging Optima’s Operations Research expertise that has been applied to the suite of products, Optima live post plan manager enables users to enjoy visually rich information to manage compliance against coverage plans. The information provided allows the dispatchers to make intelligent deployment decisions that immediately improve coverage and compliance. tm

tm

How it works Optima live post plan manager has been tuned to consider all influencing variables such as the real time road speeds, the time of day, travelling normal or lights and sirens speed. It has also been programmed to recognize historical call hotspots and uses AVL data to determine the exact location of every vehicle. Finally it captures the coverage plan and visually illustrates real time compliance along with current coverage. tm

The posts are color coded to show a simple and accurate view of compliant and non compliant locations. A dispatcher can see the depth of coverage across a given area of responsibility and make immediate deployment decisions to significantly improve current compliance. Key benefits of Optima live post plan manager are: • Color coded compliant and non compliant posts • Current location of all vehicles • Geographical drive time coverage of all available vehicles • Hot spots of historical calls • Hospitals, stations and posts tm

107

The Interface The Optima live post plan monitor interface provides the emergency dispatcher with a view of the current status of vehicles and compliance to the coverage plan. tm

The Real Time View displays all current available and assigned vehicles, the current recommended posts, current post assignment of each vehicle and the compliance to this coverage plan. The color of the circles identifies posts in compliance (green), out of compliance (red) or over compliant (blue). Additionally, if there are alternate posts depending on type of vehicle, these share the same internal color.

tm

This enables the dispatcher to quickly visualize the status and enables deployment decisions to be made efficiently. POST PLAN RECOMMENDER Based on vehicle availability, their location and the plan logic, the Post Plan Compliance interface will also recommend with an arrow which vehicles to deploy to which posts.

POST PLAN RECOMMENDER

POST PLAN MONITOR

The blue colored shading represents the depth of coverage (the darker the blue the greater the depth of coverage), call hot spots are in red and the red line identifies the assignment of a vehicle.

As vehicles become available or are assigned to calls Optima live post plan monitor dynamically updates the display with the revised posting plan.

108

www.theoptimacorporation.com 109

predict

Predict By using advanced mathematical based technology we fuse your organizations staff, transport and the community’s requirements together to enable them to work as one. We provide both accurate ‘real time’ and ‘long term’ strategic recommendations that enable organizations to operate at a higher level of efficiency, make better decisions and face fewer challenges.

110

IMAGINE BEING ABLE TO ACCURATELY SIMULATE ANY “WHAT-IF” SCENARIO.

What would happen if your operation experienced a 10 percent increase in call volume? Would you be able to present a compelling case for increased system funding? If hospital offload times increased or if one of the hospitals in your community closed or changed specialization, how would it impact your staffing requirements and response times, and what would you do to ensure performance was maintained? What would happen if you changed the mix of crews and vehicles at certain bases? What would happen if there was paramedic strike action planned? When it comes to handling the unknown, you can’t afford to rely on an intuitive guess. Strategic planners in today’s emergency services require intelligent decision support at their fingertips. Optima predict is the only commercially proven simulation based planning solution that has been designed specifically for emergency services. Optima predict enables operations and planning personnel to model endless “what-if?” scenarios and examine the likely benefits (or otherwise) of those scenarios. tm

tm

Optima predict is an interactive strategic planning solution for emergency services that provides a platform for effective planning and simulation of resource requirements. Optima predict takes into account key performance indicators such as response times, vehicle types and coverage, shift rosters, post locations and hospital ramp times to enable users to quickly build scenarios that make logistical and business sense. tm

tm

Optima predict uses the simulation of emergency calls with the response to those calls, and sophisticated analytical tools to provide the critical feedback needed to make complex resource cost/benefit decisions. Optima predict provides decision-makers with the tools to optimize operational strategies and provides the evidence to support decisions. tm

tm

Optima predict can be used to estimate call volume, for the coming year and beyond, test different coverage and posting plans, test alternative rostering strategies and then analyze their impact enabling the organization to select the most effective option and take action. tm

All of this is achieved by using Optima predict ‘s simulation and modelling capabilities before time, effort, resources and real money is spent on changing the operation. tm

111

A USER CAN: • Analyze historic data to identify trends where response targets are not being met before they become critical

Evaluate resourcing strategies: • What is the best location for a new base? • Do we need a new base or can resources be added to existing bases? Evaluate the impact of operational changes: • What is the impact of adding a new resource type? • What is the performance impact of growth in call • How does resource mix affect performance? volume? • Are all the vehicles starting at the right base? • What new demands will result from a new housing • What is the impact of changing the staffing development? schedule? • What is the impact of changes to response targets? • Do staggered shifts improve performance? • How much performance improvement is gained from new dispatch rules? During implementation, Optima predict is • How does the closure of an emergency department configured to model the specific operation and affect the ambulance service? tuned to ensure that it accurately simulates the • A hospital is no longer accepting cardiac patients: historic behavior of the service. The range of how does this impact workload? scenarios that can be simulated is unlimited. The • What is the impact of road closures or roadworks? variety of graphical displays and reports provides rich • What would happen if half the crew went on strike? tm

information to easily compare the differences of performance between multiple scenarios which in turn provides solid evidence to make strategic decisions about the future management of the organization. The illustration below demonstrates the process. First data is entered to identify any parameters of the operational model that are to be reviewed. Once the simulation is complete the results are analyzed, further changes to the model are made and then the simulation is repeated. The output of the simulation can then be used to make low risk, informed decisions about any changes to be executed within the organization.

EVIDENCE BASED DECISION MAKING

2/ANALYZE:

3/ACT: 1/SIMULATE:

112

HOW DOES IT WORK? Exploiting Optima’s Operations Research expertise, Optima predict provides a sophisticated model that enables simulation of scenarios based on changes to calls, resources or business rules. tm

CREATING A SCENARIO An Optima predict scenario takes into account various inputs including incidents, available resources, and business rules to decide how resources should be used to respond to calls. A Call Generator is included that provides the tools to create and edit the input call file and hospital selection. In addition, the Resource Editors provide the tools to edit the available resources. At any time the at-scene business rules can also be modified. tm

CALL IMPORT AND GENERATION The call import function is used to import historic calls, allowing a user to keep Optima predict up to date with the current call demand. The call generator is a tool that enables the simulation to model any changes to historic calls reflecting projected call growth or changes to call categorization. These calls are used by Optima predict in processing its scenarios. The generated calls can be: tm

tm

ROAD NETWORK

RESOURCE EDITOR

1. Based on historic calls: • Applying a simple, uniform growth rate • Applying variable growth rates by region • Copying calls from one area to another to simulate a new development 2. Randomly generated • Using statistical distributions

RESOURCE EDITORS Each Optima predict scenario comprises a number of files that specify the availability of resources and the business logic describing which resources should respond to calls and hospital selection based on the call type. The resource editors make creating and editing scenarios a straightforward process, allowing Optima predicttm to be used every day as part of the service’s planning cycle. tm

The resource editors can be used interactively with visual feedback in the Graphical Display, allowing the user to drag and drop bases, hospitals and vehicles around the system quickly and easily. SIMULATION ENGINE The heart of Optima predict is the simulation engine. Optima predict manages the full operational response from the start of the dispatch process until the resources clear the call at scene or at hospital. The simulation engine responds to each call, applying the business rules to dispatch the appropriate resources to each call, while managing the complex interactions created as other calls are processed. tm

tm

Optima predict uses a highly tuned road network to provide realistic travel times for all vehicle movements. The travel times are calibrated for each customer using optimization techniques. These techniques account for traffic congestion by time of day, for lights and sirens and normal responses and are based on historic call and AVL data. tm

113

The road network display can be configured to show a number of options, including the road class, the drive-time coverage from bases or available shifts, allowing the user to visually analyze the coverage provided. Optima predict allows the user to edit the road network. This means they are able to: 1. Close down a road entirely 2. Reduce the speed on a road 3. Edit each segment of a road tm

This allows the user to create scenarios that model major roadworks, road closures due to major incidents or the impact of special events on performance. ANALYZING RESULTS When a simulation is complete, it produces output data that users can analyze and compare multiple scenarios. This enables them to identify and refine how to maximize performance improvement or fiscal accountability. Optima predict , through the native graphical user interface and the Optima predict output reports, provides multiple options for analysis of scenario outputs.

GRAPHICAL USER INTERFACE The GUI is used to create scenarios and view a scenario running in interactive mode. However, its primary purpose is to provide a number of analytical options to the user; • View various call statistics • By user selected region set • By a user defined grid overlay • Compare two or more scenarios • Filter results by call or response attributes • Display histograms for each of the statistics REPORTING The results of each simulation run can be analyzed using graphical analysis and statistics tools. The user can make use of the flexible filtering, reporting and statistical analysis functions or make comparisons with other scenarios to identify the most effective strategies to implement. A comprehensive suite of reports is provided for each simulation run.

tm

ANALYSIS TOOLS

REPORTING MONITOR

tm

114

MORE ABOUT SIMULATION Simulation is “the use of a mathematical model to recreate a situation, often repeatedly, so that the likelihood of various outcomes can be more accurately estimated”.

Discrete event simulation models have the unique ability to model and mimic the performance of complex real systems. Other models, including high-powered optimization models and analytical models, cannot take into account the dynamics of a real system and, therefore, provide less accurate results when evaluating strategies for system design or modification. This benefit of using simulation enables complex scenarios to be tested prior to any significant capital or operational expenditure. Discrete Event Simulation Models for Emergency Services An emergency services system is exactly the type of complex real-world system that can only be effectively modeled using discrete event simulation. These systems typically comprise the following components, all of which may act together to cause unforeseen interactions which directly impact the operational performance of the system: • The number of incidents and responses to which the system must respond varies by time of day and day of week. The number of incidents typically increases annually and may have strong seasonal trends. While generally patterns in incident distribution exist, individual incidents are generally unique and independent of other calls. • The location of the incident varies, generally having underlying patterns based on time of day and day of week.

• The type of incidents (call type) will vary by time of day, day or week, and may vary seasonally. • The availability of resources depends on staff schedules and frequently varies by time of day, day of week. This is further complicated by shifts starting at different geographical locations The time taken to drive on the road network (either to incidents or to other locations) is highly variable, depending on: • Traffic congestion, with time-of-day and location effects. • Road network features, such as bridges, one-way streets, long term construction and the potential for seasonal variation. • Whether vehicles are operating in emergency or non-emergency mode. • Where and when a vehicle becomes available is impacted significantly by whether the incident requires transportation of the patient to a facility providing the required services, the location of that facility, and how long the patient turnover process takes. • The capability of different vehicles and the requirement for different types of responses to have different skill-sets dispatched to scene. • The mandated/contracted operational policy, such as how to respond to the different types of incidents and the required at-scene resources and skills. • Required response time performance measures that are applied to different types of incidents and/or to different geographical regions.

Discrete Event Simulation Helps Solve Challenges with High Levels of Confidence The power of discrete event simulation allows the investigation of a broad range of possible changes in emergency service operations including impacts of: • Changes in the prioritization of calls that result in different numbers of calls being responded to emergently vs. non-emergently. • Changes to the skills required at scene which require changes in the dispatch rules. Specialized response to incidents such as STEMI, Stroke, collisions with entrapment, hazardous materials and others which can benefit from a multi-unit response can be modeled to assess their impact on response time performance achieved for all other incidents. • How changes to hospital turnover times and increasing off-load delays impact response time performance and the associated financial impact of these. • Hospital closures, hospital specialization, or new facilities can be investigated. • Initiatives to reduce the number of calls that ambulances respond to, such as nurse triage, alternative destinations for patient transport, and treat & release. • Many other proposed external changes or possible improvements to the system design or to mandated response times, performance measurements, geography, and changes to the road network.

115

Using simulation, the outcomes of the investigations into the examples described above as well as other scenarios, provides the empirical evidence to incorporate into resource planning, budgeting, and performance discussions. In all cases, management decisions can be made with the confidence that the discrete event simulation approach provides realistic modeling of detailed real-life behavior, essential to ensure that the impacts of the proposed change are actually captured in the model and accurately reflected in the response time performance. Discrete Event Simulation As Compared to Mathematical or Analytical Approaches Discrete event simulation models allow the development of detailed scenarios representing changes to any of the parameters (inputs) incorporated into the model. The scenario is run through the simulation model over an extended period of time (configurable by the service), collecting detailed statistics on key performance measures such as incident response time performance (as well as other intervals), vehicle utilization, and distance travelled. The scenario is compared against the base-line scenario (historic system performance) to identify the benefits/costs of implementing that scenario in real-life. A range of alternative scenarios can be modeled to provide the empirical evidence on which to base the management decisions to deliver optimum performance.

Unlike simulation, simple calculations based on average unit task time and unit hour utilization calculations are not able to provide a detailed understanding of operational performance. They can also not illustrate how best to improve system performance with any degree of confidence that predicted improvements will actually be delivered “on the street”. Similarly, analytic models are not able to provide the same high-quality insights into complex real-life systems as those provided by simulation models. Analytical models are required to make simplifications in model behavior in order to allow system of mathematical equations to be solved. For emergency response systems (emergency medical services, law enforcement and fire service) the best-known analytical model is Hypercube. This approach models an emergency system as a spatial queuing system and when solved it predicts the long-run system performance assuming vehicles are based at specific fixed stations.

process without substantially simplifying assumptions about total time required to process a request for service and the patient transport phase of the incident. Since it is frequent that more than 50% of incidents within a busy emergency services system are assigned to units that are mobile and not actually at a fixed location (station or post), the key assumption within Hypercube (fixed station modeling) can substantially impact the accuracy of analytical model results. Analytical models are simply not as sensitive to changes in the system inputs as simulation models and are not as powerful as the more advanced and detailed discrete simulation models.

Simple but important operational behaviors (especially within emergency medical services systems) such as diverting a vehicle from a low-priority call to a high priority call are not included in this model. Analytical models are not able to model the entire emergency response

116

KEY BENEFITS OF OPTIMA PREDICT

TM

Optima predict is designed to be used frequently: creating, running and analyzing scenarios that can be integrated into day to day planning processes providing users with up to date information. This information can be used to improve response time performance, to improve planning processes, and to improve your financial management. tm

Improve response time performance by modeling the impact of operational changes on response time performance, including: • Analyzing alternative operational options prior to implementing potentially costly changes • Analyze and evaluate resourcing strategies • Detailed geospatial analysis of your historic performance Analyze and plan responses to day to day trends and pressures, such as: • Increasing call volumes • Changes in call patterns and call response requirements • Increasing pressures on resource utilization and performance Plan how to meet new business challenges and radical changes before they become critical: • New response models • Changes to hospital services • New resource types and resource mixes

Take control using Optima predict , with key features that include: • An easy-to-use, GIS-based user interface to run scenarios, analyze operational behavior and compare results • A highly tuned road network to provide realistic travel times for all vehicle movement, calibrated specially for the service using advanced mathematical optimization techniques • Customizable Resource Editors that let users easily specify availability of hospitals and ambulances, as well as the business logic describing how units respond to incidents • Geospatial and statistical reporting, with flexible filtering and a wide variety of standard reporting formats • Simulation modeling based on the proven scientific approach of Operations Research tm

Help keep operating expenses under control by: • Helping plan shifts to eliminate unnecessary overtime • Ensuring utilization of only the vehicles needed • Ensuring that only the bases that are needed are used and they are located in the right place Today’s complex emergency services operational decisions require intelligent decision support. Put the power of Optima predict to work for your organization. tm

Improve your fiscal management by: • Helping ensure that new bases are in the right place • Ensuring that new vehicles and staff are acquired only when needed • Ensuring that vehicles are fully utilized • Improving business cases by providing robust evidence

www.theoptimacorporation.com 117



Optima
predicttm

 Imagine
being
able
to
accurately
simulate
any
“what‐if”
scenario.
 WHAT‐IF...?
 What
would
happen
if
your
operation
experienced
a
10
percent
increase
in
call
volume?
Would
you
be
able
to
 present
a
compelling
case
for
increased
system
funding?
If
hospital
offload
times
increased
or
if
one
of
the
 hospitals
in
your
community
closed
or
changed
specialization,
how
would
it
impact
your
staffing
requirements
and
 response
times,
and
what
would
you
do
to
ensure
performance
was
maintained?
What
would
happen
if
you
 changed
the
mix
of
crews
and
vehicles
at
certain
bases?
What
would
happen
if
there
was
paramedic
strike
action
 planned?
 When
it
comes
to
handling
the
unknown,
you
 can’t
afford
to
rely
on
an
intuitive
guess.
 Strategic
planners
in
today’s
emergency
services
 require
intelligent
decision
support
at
their
 tm fingertips.
Optima
predict 

is
the
only
 commercially
proven
simulation
based
planning
 solution
that
has
been
designed
specifically
for
 tm emergency
services.
Optima
predict 
enables
 operations
and
planning
personnel
to
model
 endless
“what
if?”
scenarios
and
examine
the
 likely
benefits
(or
otherwise)
of
those
scenarios.

 tm

Optima
predict 
is
an
interactive
strategic
 planning
solution
for
emergency
services
that
 provides
a
platform
for
effective
planning
and
 simulation
of
resource
requirements.
Optima
 tm predict 
takes
into
account
key
performance
 indicators
such
as
response
times,
vehicle
types
 and
coverage,
shift
rosters,
post
locations
and
 hospital
ramp
times
to
enable
users
to
quickly
 build
scenarios
that
make
logistical
and
business
 sense.
 tm

Optima
predict 
uses
the
simulation
of
 emergency
calls,
the
response
to
those
calls,
 and
sophisticated
analytical
tools
to
provide
the
 critical
feedback
needed
to
make
complex
 resource
cost/benefit
decisions.
Optima
 tm predict 
provides
decision‐makers
with
the
 tools
to
optimize
operational
strategies
and
 provides
the
evidence
to
support
decisions.


tm

Optima
predict 
can
be
used
to
estimate
call
 volume
for
the
coming
year
and
beyond,
test
 different
coverage
and
posting
plans,
test
 alternative
rostering
strategies
and
then
analyze
 their
impact
enabling
the
organization
to
select
 the
most
effective
option
and
take
action.

 All
of
this
is
achieved
by
using
Optima
 tm predict ‘s
simulation
and
modeling
capabilities
 before
time,
effort,
resources
and
real
money
is
 spent
on
changing
the
operation.

 A
user
can:
 •

Analyze
historic
data
to
identify
 trends
where
response
targets
are
 not
being
met
before
they
become
 critical




Evaluate
the
impact
of
operational
 changes:


o

What
is
the
performance
impact
 of
growth
in
call
volume?

o

What
new
demands
will
result
 from
a
new
housing
 development?


o

What
is
the
impact
of
changes
to
 response
targets?



o

How
much
performance
 improvement
is
gained
from
 new
dispatch
rules?



 118





o

How
does
the
closure
of
an
 emergency
department
affect
 the
ambulance
service?



o

A
hospital
is
no
longer
accepting
 cardiac
patients:
how
does
this
 impact
workload?


o

What
is
the
impact
of
road
 closures
or
road
works?


o

What
would
happen
if
half
the
 crew
went
on
strike?


Evaluate
resourcing
strategies:


tm

During
implementation,
Optima
predict 
is
 configured
to
model
the
specific
operation
and
 tuned
to
ensure
that
it
accurately
simulates
the
 historic
behavior
of
the
service.
The
range
of
 scenarios
that
can
be
simulated
is
unlimited.
The
 variety
of
graphical
displays
and
reports
provide
 rich
information
to
easily
compare
the
 differences
of
performance
between
multiple
 scenarios
which
in
turn
provides
solid
evidence
 to
make
strategic
decisions
about
the
future
 management
of
the
organization.


o

What
is
the
best
location
for
a
 new
base?



o

Do
we
need
a
new
base
or
can
 resources
be
added
to
existing
 bases?


o

What
is
the
impact
of
adding
a
 new
resource
type?



o

How
does
resource
mix
affect
 performance?


o

Are
all
the
vehicles
starting
at
 the
right
base?



The
illustration
below
demonstrates
the
 process.
First
data
is
entered
to
identify
any
 parameters
of
the
operational
model
that
are
to
 be
reviewed.
Once
the
simulation
is
complete
 the
results
are
analyzed,
further
changes
to
the
 model
are
made
and
then
the
simulation
is
 repeated.
The
output
of
the
simulation
can
then
 be
used
to
make
low
risk,
informed
decisions
 about
any
changes
to
be
executed
within
the
 organization.


o

What
is
the
impact
of
changing
 the
staffing
schedule?





o

Do
staggered
shifts
improve
 performance?



 Figure
1
Evidence
based
decision
making



 119



HOW DOES IT WORK? tm

Exploiting
Optima’s
Operations
Research
expertise,
Optima
predict 
provides
a
sophisticated
model
that
 enables
simulation
of
scenarios
based
on
changes
to
calls,
resources
or
business
rules.



Creating a Scenario tm

An
Optima
predict 
scenario
takes
into
account
 various
inputs
including
incidents,
available
 resources,
and
business
rules
to
decide
how
 resources
should
be
used
to
respond
to
calls.
A
 Call
Generator
is
included
that
provides
the
 tools
to
create
and
edit
the
input
call
file
and
 hospital
selection.
In
addition,
the
Resource
 Editors
provide
the
tools
to
edit
the
available
 resources.
At
any
time
the
at‐scene
business
 rules
can
also
be
modified.


Resource Editors tm

Each
Optima
predict 
scenario
comprises
a
 number
of
files
that
specify
the
availability
of
 resources
and
the
business
logic
describing
 which
resources
should
respond
to
calls
and
 hospital
selection
based
on
the
call
type.
The
 resource
editors
make
creating
and
editing
 scenarios
a
straightforward
process,
allowing
 tm Optima
predict 
to
be
used
every
day
as
part
of
 the
service’s
planning
cycle.


Call import and generation The
call
import
function
is
used
to
import
 historic
calls,
allowing
a
user
to
keep
Optima
 tm predict 
up
to
date
with
the
current
call
 demand.
The
call
generator
is
a
tool
that
 enables
the
simulation
to
model
any
changes
to
 historic
calls
reflecting
projected
call
growth
or
 changes
to
call
categorization.
These
calls
are
 tm used
by
Optima
predict 
in
processing
its
 scenarios.
The
generated
calls
can
be:
 •



Based
on
historic
calls:
 o

Applying
a
simple,
uniform
 growth
rate


o

Applying
variable
growth
rates
 by
region


o

Copying
calls
from
one
area
to
 another
to
simulate
a
new
 development


The
resource
editors
can
be
used
interactively
 with
visual
feedback
in
the
Graphical
Display,
 allowing
the
user
to
drag
and
drop
bases,
 hospitals
and
vehicles
around
the
system
quickly
 and
easily.


Randomly
generated
 o

using
statistical
distributions







 120


 o

Simulation Engine

Edit
each
segment
of
a
road


This
allows
the
user
to
create
scenarios
that
 model
major
roadworks,
road
closures
due
to
 major
incidents
or
the
impact
of
special
events
 on
performance.



tm

The
heart
of
Optima
predict 
is
the
simulation
 tm engine.
Optima
predict 
manages
the
full
 operational
response
from
the
start
of
the
 dispatch
process
until
the
resources
clear
the
 call
at
scene
or
at
hospital.
The
simulation
 engine
responds
to
each
call,
applying
the
 business
rules
to
dispatch
the
appropriate
 resources
to
each
call,
while
managing
the
 complex
interactions
created
as
other
calls
are
 processed.


Analyzing results When
a
simulation
is
complete,
it
produces
 output
data
that
users
can
analyze
and
compare
 multiple
scenarios.
This
enables
them
to
identify
 and
refine
how
to
maximize
performance
 improvement
or
fiscal
accountability.

Optima
 tm predict ,
through
the
native
graphical
user
 tm interface
and
the
Optima
predict 
output
 reports,
provides
multiple
options
for
analysis
of
 scenario
outputs.


Road Network

Graphical user interface The
GUI
is
used
to
create
scenarios
and
view
a
 scenario
running
in
interactive
mode.
However,
 its
primary
purpose
is
to
provide
a
number
of
 analytical
options
to
the
user.
 




tm

Optima
predict 
uses
a
highly
tuned
road
 network
to
provide
realistic
travel
times
for
all
 vehicle
movements.
The
travel
times
are
 calibrated
for
each
customer
using
optimization
 techniques.
These
techniques
account
for
traffic
 congestion
by
time
of
day,
for
lights
and
sirens
 and
normal
responses
and
are
based
on
historic
 call
and
AVL
data.
The
road
network
display
can
 be
configured
to
show
a
number
of
options,
 including
the
road
class,
the
drive‐time
coverage
 from
bases
or
available
shifts,
allowing
the
user
 to
visually
analyze
the
coverage
provided.


View
various
call
statistics

 o

by
user
selected
region
set



o

by
a
user
defined
grid
overlay




Compare
two
or
more
scenarios




Filter
results
by
call
or
response
 attributes




Display
histograms
for
each
of
the
 statistics


tm

Optima
predict 
allows
the
user
to
edit
the
 road
network.
This
means
they
are
able
to:
 o

Close
down
a
road
entirely


o

Reduce
the
speed
on
a
road






 
 121



Reporting 
 The
results
of
each
simulation
run
can
be
analyzed
using
graphical
analysis
and
statistics
tools.
The
user
 can
make
use
of
the
flexible
filtering,
reporting
and
statistical
analysis
functions
or
make
comparisons
 with
other
scenarios
to
identify
the
most
effective
strategies
to
implement.
A
comprehensive
suite
of
 reports
is
provided
for
each
simulation
run.
 





 122



KEY BENEFITS OF OPTIMA PREDICT T M tm

Optima
predict 
is
designed
to
be
used
frequently:
creating,
running
and
analyzing
scenarios
that
can
be
 integrated
into
day
to
day
planning
processes
providing
users
with
up
to
date
information.
This
 information
can
be
used
to
improve
response
time
performance,
to
improve
planning
processes,
and
to
 improve
the
financial
management. •

Improve
response
time
 performance
by
modeling
the
 impact
of
operational
changes
on
 response
time
performance,
 including:
 o









Analyzing
alternative
 operational
options
prior
to
 implementing
potentially
costly
 changes


o

Analyze
and
evaluate
resourcing
 strategies


o

Detailed
geospatial
analysis
of
 historic
performance




Help
keep
operating
expenses
under
 control
by:
 o

Helping
plan
shifts
to
eliminate
 unnecessary
overtime


o

Ensuring
utilization
of
only
the
 vehicles
needed


o

Ensuring
that
only
the
bases
that
 are
needed
are
used
and
they
 are
located
in
the
right
place
 tm

Take
control
using
Optima
predict ,
 with
key
features
that
include:
 o

An
easy‐to‐use,
GIS‐based
user
 interface
to
run
scenarios,
 analyze
operational
behavior
 and
compare
results


o

A
highly
tuned
road
network
to
 provide
realistic
travel
times
for
 all
vehicle
movement,
calibrated
 specially
for
the
service
using
 advanced
mathematical
 optimization
techniques


o

Customizable
Resource
Editors
 that
let
users
easily
specify
 availability
of
hospitals
and
 ambulances,
as
well
as
the
 business
logic
describing
how
 units
respond
to
incidents


o

Geospatial
and
statistical
 reporting,
with
flexible
filtering
 and
a
wide
variety
of
standard
 reporting
formats


o

Simulation
modeling
based
on
 the
proven
scientific
approach
of
 Operations
Research



Analyze
and
plan
responses
to
day
 to
day
trends
and
pressures,
such
 as:
 o

Increasing
call
volumes


o

Changes
in
call
patterns
and
call
 response
requirements


o

Increasing
pressures
on
resource
 utilization
and
performance


Plan
how
to
meet
new
business
 challenges
and
radical
changes
 before
they
become
critical:
 o

New
response
models


o

Changes
to
hospital
services


o

New
resource
types
and
 resource
mixes


Improve
fiscal
management
by:
 o

Helping
ensure
that
new
bases
 are
in
the
right
place


o

Ensuring
that
new
vehicles
and
 staff
are
acquired
when
needed


o

Ensuring
that
vehicles
are
fully
 used


o

Improving
business
cases
by
 providing
robust
evidence


Today’s
complex
emergency
services
 operational
decisions
require
intelligent
 decision
support.
Put
the
power
of
Optima
 tm predict 
to
work
for
your
organization.



 123



MORE ABOUT SIMULATION Simulation
is
“the
use
of
a
mathematical
model
to
recreate
a
situation,
often
repeatedly,
so
that
the
 likelihood
of
various
outcomes
can
be
more
accurately
estimated”.


 Discrete event
simulation
models
have
the
 unique
ability
to
model
and
mimic
the
 performance
of
complex
real
systems.

Other
 models,
including
high‐powered
optimization
 models
and
analytical
models,
cannot
take
into
 account
the
dynamics
of
a
real
system
and,
 therefore,
provide
less
accurate
results
when
 evaluating
strategies
for
system
design
or
 modification.





The
type
of
incidents
(call
type)
will
 vary
by
time
of
day,
day
of
week,
and
 may
vary
seasonally.






The
availability
of
resources
depends
 on
staff
schedules
and
frequently
 varies
by
time
of
day,
day
of
week.
 This
is
further
complicated
by
shifts
 starting
at
different
geographical
 locations




The
time
taken
to
drive
on
the
road
 network
(either
to
incidents
or
to
 other
locations)
is
highly
variable,
 depending
on:


This
benefit
of
using
simulation
enables
complex
 scenarios
to
be
tested
prior
to
any
significant
 capital
or
operational
expenditure.
 Discrete
Event
Simulation
Models
for
 Emergency
Services
 An
emergency
services
system
is
exactly
the
 type
of
complex
real‐world
system
that
can
only
 be
effectively
modeled
using
discrete
event
 simulation.

These
systems
typically
comprise
 the
following
components,
all
of
which
may
act
 together
to
cause
unforeseen
interactions
which
 directly
impact
the
operational
performance
of
 the
system:
 •



The
number
of
incidents
and
 responses
to
which
the
system
must
 respond
varies
by
time
of
day
and
 day
of
week.
The
number
of
 incidents
typically
increases
annually
 and
may
have
strong
seasonal
 trends.

While
generally
patterns
in
 incident
distribution
exist,
individual
 incidents
are
generally
unique
and
 independent
of
other
calls.
 The
location
of
the
incident
varies,
 generally
having
underlying
patterns
 based
on
time
of
day
and
day
of
 week.


o

Traffic
congestion,
with
time‐of‐ day
and
location
effects.


o

Road
network
features,
such
as
 bridges,
one‐way
streets,
long
 term
construction
and
the
 potential
for
seasonal
variation.


o

Whether
vehicles
are
operating
 in
emergency
or
non‐emergency
 mode.




Where
and
when
a
vehicle
becomes
 available
is
impacted
significantly
by
 whether
the
incident
requires
 transportation
of
the
patient
to
a
 facility
providing
the
required
 services,
the
location
of
that
facility,
 and
how
long
the
patient
turnover
 process
takes.




The
capability
of
different
vehicles
 and
the
requirement
for
different
 types
of
responses
to
have
different
 skill‐sets
dispatched
to
scene.




The
mandated/contracted
 operational
policy,
such
as
how
to
 respond
to
the
different
types
of
 incidents
and
the
required
at‐scene
 resources
and
skills.





 124


 •

Required
response
time
 performance
measures
that
are
 applied
to
different
types
of
 incidents
and/or
to
different
 geographical
regions.


Discrete
Event
Simulation
Helps
Solve
 Challenges
with
High
Levels
of
Confidence
 The
power
of
discrete
event
simulation
allows
 the
investigation
of
a
broad
range
of
possible
 changes
in
emergency
service
operations
 including
impacts
of:
 •

Changes
in
the
prioritization
of
calls
 that
result
in
different
numbers
of
 calls
being
responded
to
emergently
 vs.
non‐emergently.





Changes
to
the
skills
required
at
 scene
which
require
changes
in
the
 dispatch
rules.

Specialized
response
 to
incidents
such
as
STEMI,
Stroke,
 collisions
with
entrapment,
 hazardous
materials
and
others
 which
can
benefit
from
a
multi‐unit
 response
can
be
modeled
to
assess
 their
impact
on
response
time
 performance
achieved
for
all
other
 incidents.





How
changes
to
hospital
turnover
 times
and
increasing
off‐load
delays
 impact
response
time
performance
 and
the
associated
financial
impact
 of
these.






Hospital
closures,
hospital
 specialization,
or
new
facilities
can
 be
investigated.




Initiatives
to
reduce
the
number
of
 calls
that
ambulances
respond
to,
 such
as
nurse
triage,
alternative
 destinations
for
patient
transport,
 and
treat
&
release.




Many
other
proposed
external
 changes
or
possible
improvements
to
 the
system
design
or
to
mandated
 response
times,
performance
 measurements,
geography,
and
 changes
to
the
road
network.


Using
simulation,
the
outcomes
of
the
 investigations
into
the
examples
described
 above
as
well
as
other
scenarios,
provides
the
 empirical
evidence
to
incorporate
into
resource
 planning,
budgeting,
and
performance
 discussions.

In
all
cases,
management
decisions
 can
be
made
with
the
confidence
that
the
 discrete
event
simulation
approach
provides
 realistic
modeling
of
detailed
real‐life
behavior,
 essential
to
ensure
that
the
impacts
of
the
 proposed
change
are
actually
captured
in
the
 model
and
accurately
reflected
in
the
response
 time
performance.
 Discrete
Event
Simulation
As
Compared
to
 Mathematical
or
Analytical
Approaches
 Discrete
event
simulation
models
allow
the
 development
of
detailed
scenarios
representing
 changes
to
any
of
the
parameters
(inputs)
 incorporated
into
the
model.
The
scenario
is
run
 through
the
simulation
model
over
an
extended
 period
of
time
(configurable
by
the
service),
 collecting
detailed
statistics
on
key
performance
 measures
such
as
incident
response
time
 performance
(as
well
as
other
intervals),
vehicle
 utilization,
and
distance
travelled.
The
scenario
 is
compared
against
the
base‐line
scenario
 (historic
system
performance)
to
identify
the
 benefits/costs
of
implementing
that
scenario
in
 real‐life.

A
range
of
alternative
scenarios
can
be
 modeled
to
provide
the
empirical
evidence
on
 which
to
base
the
management
decisions
to
 deliver
optimum
performance.

 Unlike
simulation,
simple
calculations
based
on
 average
unit
task
time
and
unit
hour
utilization
 calculations
are
not
able
to
provide
a
detailed
 understanding
of
operational
performance.
 They
can
also
not
illustrate
how
best
to
improve
 system
performance
with
any
degree
of
 confidence
that
predicted
improvements
will
 actually
be
delivered
“on
the
street”.

Similarly,
 analytic
models
are
not
able
to
provide
the
 same
high‐quality
insights
into
complex
real‐life
 systems
as
those
provided
by
simulation
 models.
Analytical
models
are
required
to
make
 
 125


 simplifications
in
model
behavior
in
order
to
allow
a
system
of
mathematical
equations
to
be
solved.

For
 emergency
response
systems
(emergency
medical
services,
law
enforcement
and
fire
service)
the
best‐ known
analytical
model
is
Hypercube.
This
approach
models
an
emergency
system
as
a
spatial
queuing
 system
and
when
solved
it
predicts
the
long‐run
system
performance
assuming
vehicles
are
based
at
 specific
fixed
stations.


 Simple
but
important
operational
behaviors
(especially
within
emergency
medical
services
systems)
such
 as
diverting
a
vehicle
from
a
low‐priority
call
to
a
high
priority
call
are
not
included
in
this
model.

 Analytical
models
are
not
able
to
model
the
entire
emergency
response
process
without
substantially
 simplifying
assumptions
about
total
time
required
to
process
a
request
for
service
and
the
patient
 transport
phase
of
the
incident.
Since
it
is
frequent
that
more
than
50%
of
incidents
within
a
busy
 emergency
services
system
are
assigned
to
units
that
are
mobile
and
not
actually
at
a
fixed
location
 (station
or
post),
the
key
assumption
within
Hypercube
(fixed
station
modeling)
can
substantially
impact
 the
accuracy
of
analytical
model
results.
Analytical
models
are
simply
not
as
sensitive
to
changes
in
the
 system
inputs
as
simulation
models
and
are
not
as
powerful
as
the
more
advanced
and
detailed
discrete
 simulation
models.









 126



OPTIMA
 THE
OPTIMA
PROMISE
 By
using
advanced
mathematical
based
technology
we
fuse
your
organizations
staff,
transport
and
the
 community’s
requirements
together
to
enable
them
to
work
as
one.

We
provide
both
accurate
‘real
 time’
and
‘long
term’
strategic
recommendations
that
enable
organizations
to
operate
at
a
higher
level
 of
efficiency,
make
better
decisions
and
face
fewer
challenges.


ABOUT
US
 Optima
is
a
world
leading
Operations
Research
 company
that
delivers
best
in
class
optimization
and
 simulation
software
solutions
for
select
global
 markets.
Currently
focused
in
the
Emergency
 Services,
Airline
and
Health
industries.
 The
Optima
Corporation
was
founded
in
1998
by
 Auckland
University
Engineering
Science
members
 Professor
David
Ryan
and
Dr
Andrew
Mason
 together
with
graduate
Dr
Paul
Day.
Optima’s
 strength
comes
from
the
experience
of
its
founders
 in
implementing
advanced
Operations
Research
 techniques
for
companies
such
as
Air
New
Zealand,
 enabling
dramatic
reduction
in
business
costs
while
 concurrently
improving
operational
effectiveness.
 Optima‘s
solutions
have
quickly
forged
an
 international
reputation
as
market
leaders
with
a
 rapidly
growing
customer
base
in
Europe,
North
 America,
Australia
and
New
Zealand.
We
now
have
 offices
in
Oxford,
England
and
Austin,
Texas
in
the
 United
States,
as
well
as
partners
in
Scandinavia
and
 Spain.
 Our
team
of
people
has
extensive
knowledge
in
 Operations
Research,
with
a
significant
number
 having
PhD
and
Masters
Qualifications.
They
are
 globally
recognized
for
their
industry
expertise
and
 ability
to
provide
leading
edge
and
innovative
 solutions.


OPTIMA’S
CREDENTIALS
 •

Optima
provides
sophisticated
optimization
 and
simulation
solutions
to
real
world
 business
challenges
saving
our
customers
 money
and
increasing
productivity




Our
suite
of
products,
Optima
predict 
and
 tm Optima
live 
are
commercially
proven
 simulation
based
planning
and
dynamic
 deployment
software
designed
especially
 for
Emergency
Services.




Optima’s
respected
personnel
have
 designed,
implemented
and
managed
highly
 complex
emergency
services
solutions
 worldwide




Satisfied
customers
include
Air
New
 Zealand,
Ambulance
Victoria,
Toronto
 Emergency
Medical
Services,
South
Central
 Ambulance
Service
(UK)
and
Lee
County
in
 Florida,
USA.




Optima
maintains
a
very
strong
partnership
 with
the
Department
of
Engineering
Science
 at
Auckland
University,
world
leaders
in
 Emergency
Services
and
Airline
scheduling.




High
quality
CEO,
Management
and
Board
 who
have
extensive
experience
in
 international
operations.


tm

127



The
term
“Operations
Research”
describes
the
 discipline
of
applying
advanced
analysis
methods
to
 help
make
better
business
decisions.

Operations
 Research
methods
and
technologies
have
 traditionally
played
an
important
role
in
business
 areas
such
as
supply
chain
planning,
chemicals,
 manufacturing,
aviation,
logistics,
 telecommunications
network
design
and
operations
 as
well
as
throughout
the
military.

Typically
 Operations
Research
tools
are
delivered
as
high‐tech
 computer‐based
systems,
decision
support
systems,
 and/or
command/control
systems.

These
 Operations
Research
systems
provide
important
 evidence
and
insights
helping
executives
and
 managers
to
make
key
decisions,
to
solve
pressing
 problems,
and
to
plan
and
adjust
their
“best”
 strategies.
The
application
of
Operations
Research
 leads
to
improved
productivity,
lower
costs
of
 operations,
reduction
in
risk
and
more
efficient
use
 of
limited
resources.



Approaches
fall
broadly
into
 three
major
categories:


UNIVERSITY
RELATIONSHIPS
 A
major
strength
of
Optima
is
the
relationships
we
 have
with
many
Universities
across
the
globe.
We
 are
able
to
share
and
challenge
the
latest
innovative
 thinking
for
Operations
Research
with
the
best
 expertise
around
the
world
and
explore
how
we
 apply
that
to
continuously
enhance
and
develop
our
 own
solutions.
The
benefit
of
this
ensures
our
 products
remain
leading
edge
and
captures
the
most
 internationally
advanced
thinking.
 Some
of
the
relationships
we
have
today
include
 University
of
Auckland,
New
Zealand,
University
of
 Arizona,
USA,
and
Cornell
University,
New
York,
USA.


OPERATIONS
RESEARCH
 Optima’s
Operations
Research
experience
is
the
 foundation
of
the
company.
The
staff
are
globally
 recognized
leaders
in
Operations
Research.
The
 combination
of
Optima’s
expertise
and
detailed
 industry
knowledge
allows
delivery
of
the
following
 value:


Simulation
–
allowing
“dry‐run”
of
different
 approaches
on
computer
models,
to
investigate
 scenarios
and
to
find
and
test
ideas
for
improvement



Expertise
in
modeling
real‐life
systems,
including
 Emergency
systems


Optimization
–
mathematical
models
used
to
select
 the
best
possible
solutions,
from
a
multitude
of
 choices


Expertise
in
advanced
optimization
and
simulation
to
 solve
complex
business
challenges
across
a
wide
 range
of
industries


Data Analysis
‐
detection
of
patterns
and
 connections
in
data,
providing
insights
for
 forecasting



Highly
configurable
software
designed
specifically
to
 solve
Emergency
Service
challenges


Most
importantly,
the
analysis
that
Operations
 Research
provides
is
vastly
more
powerful
than
non‐ Operations
Research
analysis,
such
as
projections
 based
on
standard
spreadsheet
studies,
simple
 regression
or
other
models.


Operations
Research
uses
detailed
analysis,
 modeling
and
advanced
algorithms
to
solve
complex
 business
challenges.
Optima’s
practical
modeling
 experience
across
a
number
of
industries
combined
 with
its
extensive
emergency
services
experience
 gained
through
working
directly
with
customers
for
 ten
years
has
resulted
in
highly‐configurable
 software
solutions
capturing
key
real‐life
behaviors
 essential
to
providing
consistently
high‐quality
 decisions.




128



OPTIMA’S
SOLUTIONS
 tm

“Optima
live 
moved
a
vehicle
from
‘A’
to
‘B’
–
a
move
that
apparently
would
never
be
normally
contemplated.
In
 the
course
of
the
vehicle
being
moved,
a
one
month
old
baby
had
a
heart
attack,
and
the
vehicle
was
‘just
around
 the
corner’
arriving
in
six
minutes
instead
of
an
expected
25
minutes.”
 Ron
Eke
‐
Head
of
Communications
–
Ambulance
Victoria

 Within
the
Emergency
Service
optimization
technology
sector,
Optima
is
recognized
for
providing
innovative
world
 leading
simulation
and
optimization
business
solutions.
 Our
core
products
for
emergency
services
include:


EMERGENCY
SERVICES


tm

Optima
predict 
 –
Optima’s
 simulation
 based
planning
solution
that
enables
 operations
and
planning
personnel
to
 model
endless
“what
if?”
scenarios
 and
examine
the
likely
benefits
(or
 otherwise)
of
those
scenarios
before
 committing
time,
effort,
resources,
 and
capital
to
these
system
design
 options.


With
numerous
global
customers
the
Emergency
 Services
market
provides
a
key
focus
for
Optima.
 Optima
proudly
offer
a
number
of
solutions
to
the
 Emergency
Services
industry.
Our
two
suites
of
 tm tm products
are
Optima
predict 
and
Optima
live .


OPTIMA
PREDICT T M 
 tm

Optima
predict 
is
a
strategic
planning
and
 modeling
tool
that
simulates
real
time
activities.
It
 has
been
designed
specifically
for
emergency
 services.
It
allows
organizations
to
accurately
plan
 for
and
accommodate
the
future
impact
of
 geographical
growth,
road
network
changes,
special
 events
and
other
resourcing
demands.
It
simulates
 responses
(end‐to‐end
discrete
simulation)
to
 emergency
calls
and
includes
sophisticated
analytical
 tools
to
provide
the
information
needed
to
make
 complex
operational
decisions.



tm

Optima
live 
–
 Optima’s
real
 time
dynamic
 deployment
solutions
that
 incorporates
predictive
analytics
to
 assist
dispatchers
with
emerging
 coverage
challenges,
while
at
the
same
 time
making
optimized
 recommendations
for
unit
 deployment.
 Optima’s
strategy
is
to
have
its
solutions
become
the
 default
for
advanced
planning
and
decision
support
 for
Emergency
Service
organization
world‐wide.


OPTIMA
LIVE T M 
 tm

The
suite
of
Optima
live 
products
provides
real
 time
decision
support
to
emergency
dispatch
centers
 responsible
for
assigning
vehicles
to
emergency
calls.



In
addition
Optima
continues
to
work
within
other
 industries
such
as
Airlines,
Healthcare
and
Sport
to
 improve
efficiencies
and
reduce
costs.


tm

The
Optima
live 
products
are
Post
Plan
Manager,
 Deployment
and
Dispatch.
They
calculate




129



deployment
recommendations
that
include
 consideration
of
real
time
traffic
flows,
availability
 and
location
of
emergency
vehicles
and
current
call
 demands
in
specific
geographical
locations.
Optima
 tm live 
does
this
by
applying
mathematical
models
to
 real‐time
data
in
an
easy
to
use
application.
By
 putting
sophisticated
analytical
tools
into
the
 tm dispatch
center,
Optima
live 
products
ensure
that
 an
emergency
dispatch
system
can
have
its
vehicles
 in
the
right
place
at
the
right
time,
improving
 performance
and
making
the
best
use
of
the
 available
resources.


level
of
coverage.
They
then
apply
a
set
of
business
 rules
to
work
out
the
status
and
location
of
vehicles
 in
the
near
future
(look‐ahead
situation)
and
the
 tm coverage
provided.
Finally
the
Optima
live 
 optimizer
identifies
the
best
locations
for
the
 currently
available
vehicles,
according
to
historic
 incident
demand
patterns
and
configured
business
 rules.
This
whole
calculation
process
all
occurs
within
 a
few
seconds.
 tm

The
Optima
live 
system
is
time
sensitive:
it
knows,
 for
example,
the
difference
between
a
Sunday
 morning,
a
Monday
afternoon
and
a
Thursday
 evening.
Different
road
speeds
account
for
different
 traffic
patterns;
call
data
is
sampled
from
similar
 times
and
appropriate
system
specific
business
rules
 can
be
applied.


tm

All
Optima
live 
products
receive
data
from
the
 Computer
Aided
Dispatch
(CAD)
system
on
current
 vehicle
locations
and
statuses.
From
this
data,
they
 use
the
tuned
road
network
to
calculate
the
current


MORE
ABOUT
OPTIMIZATION
 Optimization
provides
compelling
solutions
to
complex
business
challenges.
 Optimization
uses
proven
mathematical
models
to
identify
the
best
possible
solutions.
It
calculates
all
possible
 outcomes
for
dynamic
and
complex
business
issues
to
provide
the
most
effective
solution.
The
mathematical
 formulae
consider
factors
such
as:
 • • • • •

Dynamic
traffic
flows
 Staff
rosters
 Unplanned
delays
and
diversions
 Historical
demands
 Business
rules
such
as
mode
of
operation


The
power
of
optimization
allows
the
above
factors
to
be
dynamically
modeled
in
real
time
thus
providing
 immediate
recommendations.
This
enables
the
optimal
usage
of
available
resources
at
any
given
point
in
time.




130



THE
CHALLENGES
IN
DEPLOYMENT
FOR
EMERGENCY
SERVICES
 Optimization
is
the
ideal
approach
to
solve
complex
 deployment
 decisions
 for
 emergency
 services.
 Typically
 deployment
 involves
 the
 dispatcher
 deciding
 where
 to
 post
 the
 available
 vehicles
 to
 achieve
 the
 best
 possible
 coverage,
 while
 at
 the
 same
 time
 considering
 the
 impact
 of
 the
 decisions
 on
the
crews.


The dispatcher has to take into account the crew  they are deploying  • The
 service
 is
 likely
 to
 have
 agreements
 with
 staff
 around
 meal
 breaks,
 end
 of
 shift
 and
other
working
conditions
that
all
affect
 the
options
available
to
the
dispatcher
 • Services
often
prefer
to
keep
vehicles
close
 to
their
home
station
or
area


In
a
typical
emergency
service:


The dispatcher is often responsible for dispatch and  unable to manually optimize deployment when the  dispatch becomes more demanding 

The dispatcher has a fleet of vehicles  • In
 a
 large
 service
 they
 could
 easily
 be
 managing
100
or
more
vehicles
 • The
availability
and
location
of
each
vehicle
 changes
 throughout
 the
 shift
 as
 vehicles
 respond
 to
 incidents,
 travel
 to
 destination
 and
return
to
base


Real
Time
Optimization
for
Deployment
 Real
Time
Optimization
is
ideally
suited
for
solving
 deployment
challenges
because
it
simultaneously
 considers
all
possible
deployment
alternatives
while
 respecting
the
business
rules
that
govern
 deployment
in
a
given
environment.


The traffic and road conditions will change  throughout the shift and throughout the week  • Traffic
 conditions
 change
 as
 people
 move
 around
 the
 geography,
 creating
 rush
 hours
 and
quiet
periods
 • Traffic
affects
how
long
it
will
take
a
vehicle
 to
 drive
 to
 a
 location
 and
 therefore
 the
 coverage
 that
 can
 be
 provided
 from
 any
 given
location






The dispatcher has a combination of stations, posts,  and other deployment points to which they can send  the vehicles  • This
 list
 may
 change
 during
 the
 course
 of
 the
shift:
for
example,
some
posts
may
only
 be
used
during
daylight
hours






The dispatcher has a large geography to cover  • Perhaps
thousands
of
square
miles,
much
of
 which
may
be
unfamiliar
to
the
dispatcher
 • Urban
v
Rural
considerations


• •

The dispatcher must cover rapidly changing call  demand   • During
a
day,
call
patterns
will
change
 • Seasonal
 effects
 will
 change
 the
 pattern
 over
the
course
of
a
year




Optimization
 can
 use
 a
 dynamic
 coverage
 calculation,
 allowing
 for
 variability
 in
 coverage
 provided
 by
 road
 network
 conditions
 Optimization
 can
 use
 a
 dynamic
 call
 demand
function,
allowing
for
different
call
 demand
during
the
course
of
a
day,
or
over
 the
course
of
a
year
 Using
real‐time
AVL
and
Status
data
from
a
 Computer
 Aided
 Dispatch
 System,
 Optimization
can
know
the
current
location
 and
 availability
 of
 every
 vehicle
 in
 the
 system
 Optimization
 can
 include
 costs
 and
 constraints
to
model
business
rules
 Moving
a
vehicle
a
long
way
can
cost
more
 than
moving
a
vehicle
a
short
way
 Optimization
 can
 require
 that
 vehicles
 return
home
for
the
end
of
their
shift
 Optimization
 will
 provide
 consistent
 recommendations
 regardless
 of
 the
 workload
of
the
system
–
or
the
dispatcher.




131



MORE
ABOUT
SIMULATION
 Simulation
is
“the
use
of
a
mathematical
model
to
recreate
a
situation,
often
repeatedly,
so
that
the
likelihood
of
 various
outcomes
can
be
more
accurately
estimated.”.


 Discrete event
simulation
models
have
the
unique
ability
to
model
and
mimic
the
performance
of
complex
real
 systems.

Other
models,
including
high‐powered
optimization
models
and
analytical
models,
cannot
take
into
 account
the
dynamics
of
a
real
system
and,
therefore,
provide
less
accurate
results
when
evaluating
strategies
for
 system
design
or
modification.

 This
benefit
of
using
simulation
enables
complex
scenarios
to
be
tested
prior
to
any
significant
capital
or
 operational
expenditure.


DISCRETE
EVENT
SIMULATION
MODELS
FOR
EMERGENCY
SERVICES
 •

An
emergency
services
system
is
exactly
the
type
of
 complex
real‐world
system
that
can
only
be
 effectively
modeled
using
discrete
event
simulation.

 These
systems
typically
comprise
the
following
 components,
all
of
which
may
act
together
to
cause
 unforeseen
interactions
which
directly
impact
the
 operational
performance
of
the
system:
 •

The
location
of
the
incident
varies,
generally
 having
underlying
patterns
based
on
time
of
 day
and
day
of
week.




The
type
of
incidents
(call
type)
will
vary
by
 time
of
day,
day
of
week,
and
may
vary
 seasonally.






The
availability
of
resources
depends
on
 staff
schedules
and
frequently
varies
by
 time
of
day
and
day
of
week.
This
is
further
 complicated
by
shifts
starting
at
different
 geographical
locations


Traffic
congestion,
with
time
of
day
 and
location
effects.
 o Road
network
features,
such
as
 bridges,
one‐way
streets,
long
term
 construction
and
the
potential
for
 seasonal
variation.
 o Whether
vehicles
are
operating
in
 emergency
or
non‐emergency
 mode.
 Where
and
when
a
vehicle
becomes
 available
is
impacted
significantly
by
 whether
the
incident
requires
 transportation
of
the
patient
to
a
facility
 providing
the
required
services,
the
location
 of
that
facility,
and
how
long
the
patient
 turnover
process
takes.
 o

The
number
of
incidents
to
which
the
 system
must
respond
varies
by
time
of
day
 and
day
of
week.
The
number
of
incidents
 typically
increases
annually
and
may
have
 strong
seasonal
trends.

While
generally
 patterns
in
incident
distribution
exist,
 individual
incidents
are
usually
unique
and
 independent
of
other
calls.




The
time
taken
to
drive
on
the
road
 network
(either
to
incidents
or
to
other
 locations)
is
highly
variable,
depending
on:






The
capability
of
different
vehicles
and
the
 requirement
for
different
types
of
response
 to
have
different
skill‐sets
dispatched
to
 scene.




The
mandated/contracted
operational
 policy,
such
as
how
to
respond
to
the
 different
types
of
incident
and
the
required
 at‐scene
resources
and
skills.





 


132





Required
response
time
performance
 measures
that
are
applied
to
different
types
 of
incident
and/or
to
different
geographical
 regions.


modeled
to
assess
their
impact
on
response
 time
performance
achieved
for
all
other
 incidents.

 •

How
changes
to
hospital
turnover
times
and
 increasing
off‐load
delays
impact
response
 time
performance
and
the
associated
 financial
impact
of
these.






Hospital
closures,
hospital
specialization,
or
 new
facilities
can
be
investigated.


Discrete
Event
Simulation
Helps
Solve
Challenges
 with
High
Levels
of
Confidence
 The
power
of
discrete
event
simulation
allows
the
 investigation
of
a
broad
range
of
possible
changes
in
 emergency
service
operations
including
impacts
of:
 •

Changes
in
the
prioritization
of
calls
that
 result
in
different
numbers
of
calls
being
 responded
to
emergently
vs.
non‐ emergently.





Initiatives
to
reduce
the
number
of
calls
 that
vehicles
respond
to,
such
as
nurse
 triage,
alternative
destinations
for
patient
 transport,
and
treat
&
release.




Changes
to
the
skills
required
at
scene
 which
require
changes
in
the
dispatch
rules.

 Specialized
response
to
incidents
such
as
 STEMI,
Stroke,
collisions
with
entrapment,
 hazardous
materials
and
others
which
can
 benefit
from
a
multi‐unit
response
can
be




Many
other
proposed
external
changes
or
 possible
improvements
to
the
system
 design
or
to
mandated
response
times,
 performance
measurements,
geography,
 and
changes
to
the
road
network.





 Using
simulation,
the
outcomes
of
the
investigations
into
the
examples
described
above
as
well
as
other
scenarios
 provide
the
empirical
evidence
to
incorporate
into
resource
planning,
budgeting,
and
performance
discussions.

In
 all
cases,
management
decisions
can
be
made
with
the
confidence
that
the
discrete
event
simulation
approach
 provides
realistic
modeling
of
detailed
real‐life
behavior,
essential
to
ensure
that
the
impacts
of
the
proposed
 change
are
actually
captured
in
the
model
and
accurately
reflected
in
the
response
time
performance.




133



THE
OPTIMA
TEAM
 This
passionate
and
dedicated
team
is
made
up
of
highly
qualified
industry
leading
individuals
who
are
collectively
 responsible
for
designing,
implementing
and
managing
some
of
the
most
sophisticated
optimization
tools
in
the
 world.
Some
of
the
team
include:‐



 
 Chris
Mackay



 






Chief
Executive
Officer




Chris
Mackay
is
the
CEO
of
The
Optima
Corporation.
Chris
has
20
years
of
experience
in
 the
IT
industry.
He
was
previously
the
CEO
for
Computerland
New
Zealand,
a
$150m
IT
 Services
Company,
he
has
been
a
director
of
a
number
of
IT
software
and
service
 companies
and
was
New
Zealand’s
only
representative
on
the
Hewlett
Packard
Asia
Pacific
 advisory
board.
His
previous
experience
includes
responsibility
for
National
Sales
and
 Service
teams,
running
a
franchise
network
and
managing
multiple
vendor
relationships
 such
as
IBM,
Hewlett
Packard,
Microsoft
and
Cisco.
He
has
strong
strategic
and
 commercial
skills
which
are
balanced
with
his
focus
on
customer
and
partner
relationships.



 
 Tim
Lynskey



 






Sales
Director,
Europe




Tim
Lynskey
joined
Optima
as
VP
Sales
in
2004.
He
majored
in
economics
and
English
at
 University
and
has
held
various
national
account
manager
and
sales
manager
roles
in
the
 transport
and
technology
sectors.
Prior
to
joining
Optima
he
spent
three
years
as
 Executive
Account
Manager
for
SAS
New
Zealand.
His
career
has
also
included
three
years
 as
National
Account
Manager
of
Rebus
Software
(formerly
Peterborough
Software)
and
 General
Sales
Manager
of
Speech
Recognition
Systems
Limited.



 




 


134 







 
 Chris
Callsen



 






Chief
Operating
Officer,
North
America





Chris
Callsen
is
an
Emergency
Medical
Services
(EMS)
and
Homeland
Security
executive
 with
almost
30
years
of
diverse
experience.
He
has
served
as
a
senior
operations
and
 clinical
executive
in
nationally
recognized
EMS
organizations
as
well
as
providing
local,
 state
and
national
leadership
through
participation
on
formal
advisory
panels
and
boards.
 Chris
was
educated
at
Georgetown
University
in
Washington,
DC
and
recently
completed
 the
Senior
Executives
in
State
and
Local
Government
program
at
Harvard
University‘s
John
 F
Kennedy
School
of
Government.




 
 Dr
Paul
Day



 






Head
of
Development




Dr
Paul
Day
is
a
founding
principal
of
Optima
who
now
heads
product
development.
He
 completed
his
Bachelor
of
Engineering
and
PhD
at
the
University
of
Auckland
in
New
 Zealand.
Paul
completed
his
PhD
research
on
aircrew
rostering
which
has
been
 successfully
implemented
at
Air
New
Zealand.
Paul
contributes
a
vast
wealth
of
knowledge
 in
the
practical
aspects
of
solving
real
business
challenges
using
optimization,
and
he
is
 responsible
for
the
software
production
engineering
process
and
the
development
of
the
 Emergency
Services
product
range.



 




 


135 







 
 Amanda
Day



 






Operations
Manager




Amanda
Day
joined
Optima
in
2006
to
manage
Optima’s
airline
business
and
is
now
 Operations
Manager
with
special
responsibility
for
support
of
Optima’s
solutions.
She
has
 a
master’s
degree
in
Operations
Research
and
10
years’
experience
in
airline
optimization
 with
Air
New
Zealand’s
Operations
Research
group.
Her
skill
set
includes
extensive
 experience
in
Project
Management.



 
 Bill
Hollins



 






Project
Director




Bill
Hollins
joined
Optima
in
December
2007.
He
brings
over
25
years’
management
 experience
both
of
people
and
projects
in
the
following
roles:
Service
Delivery
Manager,
IT
 Manager,
Project
Management,
Design
and
Development
Manager,
Operations
Manager
 and
Support
Manager.
In
addition
he
has
had
roles
as
a
Senior
Consultant
for
database
and
 storage
multinational
companies.
Bill
is
a
Prince2
Practitioner
Certified
Project
Manager
 and
has
been
involved
in
consulting
and
managing
multiple
overseas
projects
including
in
 Hong
Kong,
Malaysia,
UK,
USA,
Australia
and
Canada.




 




 


136 







 
 Dr
Geoff
Goodhew



 






Senior
Business
Analyst




Dr
Geoff
Goodhew
completed
his
PhD
in
Management
in
1998
with
in‐depth
studies
of
 change
management
and
managerial
cognition.
He
has
worked
as
a
business
and
financial
 systems
analyst
in
the
UK,
Europe
and
New
Zealand
working
on
both
implementation
and
 upgrades
of
enterprise
systems.
Geoff
is
an
expert
in
organizational
analysis
and
process
 design
and
has
redesigned
and
streamlined
several
processes
in
his
capacity
as
a
business
 analyst.
Geoff
joined
Optima
in
2006
and
is
responsible
for
planning
and
managing
 implementation
projects.
He
has
worked
with
Emergency
Medical
Services
in
Australia,
 Canada
and
The
United
Kingdom
and
is
based
in
our
UK
Office.




 
 Jim
Waite



 






Software
Architect




Graduating
in
1995
with
first
class
honours
in
his
mathematics
masters
degree,
Jim
joined
 the
operations
research
team
at
Air
New
Zealand.

While
there,
working
with
company
 founders
David
Ryan
and
Paul
Day
on
large
scale
resource
optimization
problems
he
 discovered
his
passion
and
natural
talent
for
computer
programming.

Shortly
after
the
 company
was
formed
in
the
late
‘90s,
Jim
joined
in
a
software
development
role,
and
over
 the
years
his
combination
of
mathematical
ability
and
computer
programming
know‐how
 has
led
to
the
successful
solution
of
many
difficult
technical
problems.

Jim
enjoys
what
he
 does,
and
makes
it
his
business
to
keep
abreast
of
the
latest
technological
advances
in
 software
development.





 




 


137 





 
 
 Dr
Robert
Berks




 






Development
Team
Leader




Dr
Robert
Berks
completed
a
BSc
(Hons)
majoring
in
Computer
Science
at
the
University
of
 Auckland,
New
Zealand
and
a
PhD
at
the
University
of
Waterloo,
Canada.
He
has
worked
at
 IBM
Toronto
Labs
developing
DB2
Enterprise
Edition
database,
and
at
Navman
New
 Zealand
developing
GPS
guided
car
navigation
systems.
He
also
has
academic
experience
 at
the
University
of
Auckland
as
a
lecturer
in
Software
Engineering.



 
 Dr
Oliver
Weide



 






Developer




Dr
Oliver
Weide
started
to
work
for
Optima
in
May
2008.
He
completed
his
Masters
of
 Mathematics
degree
from
the
Technical
University
of
Darmstadt
in
Germany
in
2003.
 Oliver
started
a
PhD
of
Engineering
Science
at
the
University
of
Auckland
in
2005
and
 completed
his
degree
in
February
2009.
His
research
on
robust
aircraft
and
crew
 scheduling
was
successfully
implemented
at
Air
New
Zealand
before
he
finished
his
 degree.
Oliver
works
as
a
software
developer
and
designs
mathematical
optimization
 models.
Recently,
Oliver
has
been
working
on
a
Theatre
Optimization
project
seeking
to
 optimally
allocate
surgeons
and
procedures
to
operating
theatre
sessions.



 
 Dr
Patrick
van
der
Velde




 




Developer






Dr
Patrick
van
der
Velde
started
working
for
The
Optima
Corporation
in
April
2009
as
a
 software
developer.
He
completed
his
Master
of
Science
at
Delft
University
of
Technology
 in
the
Netherlands
in
2002
which
was
followed
by
the
completion
of
his
PhD
at
the
 University
of
Auckland
in
New
Zealand
in
2009.
His
research
was
on
the
development
of
 run‐time
assembly
and
combinations
of
simulation
tools.







138 





 


139 


Optima
livetm
 Optimize
deployment
and
improve
performance
with
 enhanced
real‐time
emergency
services
decision
support.


THE
RIGHT
PLACE.
THE
RIGHT
TIME.
EVERY
TIME.

 For
an
emergency
services
system
to
maximize
 its
performance
and
make
the
best
use
of
its
 resources,
there
is
nothing
more
important
than
 ongoing
vehicle
coverage
and
accurate
 deployment
to
support
intelligent
dispatch
 decisions.

 tm

Optima
live 
is
Optima’s
world
leading
suite
of
 real
time
dynamic
deployment
solutions
that
 incorporate
predictive
analytics
to
assist
 dispatchers
with
emerging
coverage
challenges,
 while
at
the
same
time
making
optimized
 recommendations
for
unit
deployment.


status
of
resources
and
continually
optimizes
to
 find
the
best
possible
solutions.
It
is
able
to
 provide
the
communications
center
with
 realistic
deployment
recommendations
for
the
 best
possible
coverage,
minimizing
unnecessary
 moves
that
tax
crews
or
waste
fuel.
 tm

The
Optima
live 
products
provide
state‐of‐ the‐art
features
customized
for
the
center,
 including:
 •

A
highly
tuned
road
network
to
provide
 realistic
travel
times
for
all
vehicle
 movements
(lights‐and‐sirens
and
normal
 responses),
calibrated
specially
for
the
 service
using
actual
vehicle
and
call
 information




Differentiated
coverage
tiers
based
on
 vehicle
capabilities
(e.g.
first
response
or
 transport,
advanced
life
support,
etc.)




Specific
deployment
recommendations
in
 real
time
based
on
advanced
mathematical
 optimization
techniques,
with

the
 corresponding
improvement
in
coverage
 displayed
in
a
quantifiable
format




Highly
configurable
displays,
with
the
ability
 to
customize
colors
and
icons
to
match
the
 dispatch
service’s
existing
visuals




Predictive
analytic
algorithms
based
on
the
 proven
scientific
approach
of
Operations
 Research



tm

Optima
live 
provides
real‐time
decision
 support
for
emergency
services
in
an
easy‐to‐ use
graphical
interface.
It
is
run
entirely
from
 the
communications
center
providing
 information
and
accurate
recommendations
to
 dispatchers
and
supervisors
to
assist
with
the
 important
deployment
decisions
confronting
 communications
staff.
 To
deploy
vehicles
effectively,
staff
need
to
 know
more
than
just
what’s
happening
now,
 they
also
need
to
know
what
is
likely
to
happen
 tm next.
That
is
why
Optima
live 
provides
“Look
 Ahead
Technology”,
the
next
generation
of
real
 time
decision
support.
 tm

The
suite
of
Optima
live 
products
takes
into
 account
current
and
historical
call
volume
for
 the
day
of
the
week
and
time
of
day
and
then
 uses
sophisticated
predictive
analytics
that
can
 forecast
changes
in
the
system
over
the
critical
 tm next
20
minutes.
Optima
live 
monitors
the


tm

Optima
live 
real time view
is
the
foundation
 platform
that
receives,
processes
and
displays
 real
time
data
from
the
computer
aided
 tm dispatch
(CAD)
system.
Optima
live 
real time 



140

view provides
the
application
framework
for
the
 tm other
Optima
live 
products
as
well
as
 including
the
data
visualization
and
 configuration
components.

 Optima‘s
intelligent
decision
support
is
further
 enhanced
by
the
products
that
leverage
the
 tm Optima
live 
real time view
platform.
These
 are:
 •

tm

Optima
live 
dispatch
that
provides
 dispatch
recommendations
based
on
highly
 configurable
logic
thus
improving
both
the
 speed
and
accuracy
of
dispatch
 tm



Optima
live 
deployment
that
provides
 deployment
recommendations,
improving
 the
level
of
coverage
provided
by
the
 current
and
soon
to
be
available
vehicles
in
 order
to
improve
overall
response
time
 compliance




Optima
live 
post plan manager
that
 provides
a
real
time
view
of
the
post
plan
 compliance
allowing
dispatchers
to
 maintain
conformity
to
agreed
geographic
 or
demand‐driven
deployment


tm

tm

In
addition
to
these
products,
Optima
live 
 deployment
includes
a
number
of
additional
 plug‐ins
that
further
enhance
the
functionality
 available
for
real
time
decision
support.
These
 include:




Meal
Monitor
to
track
meal
breaks
assigned
 to
each
unit




Shift
Manager
to
manage
planned
shifts
and
 match
these
to
active
shifts


HOW
DOES
IT
WORK?
 tm

The
Optima
live 
real time view
platform
for
 tm the
suite
of
Optima
live 
products
is
built
up
as
 follows:


ROAD
NETWORK
 The
Road
Network
is
one
of
the
core
underlying
 tm technologies
in
Optima
live .
The
road
network
 is
used
to
perform
all
the
drive‐time
calculations
 necessary
to
calculate
coverage
and
is
used
for
 both
Deployment
and
Dispatch
decision
 support.
 The
Road
Network
is
tuned
by
means
of
 historical
vehicle
travel
information.
Optima
 uses
historic
incident
and
AVL
data
to
calculate
 realistic
drive‐times
for
each
road
segment
in
 the
model.
These
drive‐times
are
time
sensitive,
 capturing
the
difference
for
instance
between
 Monday
morning
and
Sunday
afternoon.






141

THE
REAL
TIME
WINDOW


The
Real
Time
Window
is
the
primary
graphical
 interface
through
which
the
user
interacts
with
 tm Optima
live 
products.
It
provides
a
map
 display
and
allows
the
user
to
see
the
current
 state
of
the
system,
consisting
of
the
display
 elements
as
listed
below.
By
showing
these
 elements
on
a
map,
the
user
can
quickly
 appraise
the
current
state
of
the
system.
 The
following
elements
can
be
displayed
in
 tm Optima
live :
 •

Road
Network




Vehicle
type
and
location





Vehicle
coverage




Call
hotspots




Location
of
stations,
posts
&
hospitals


CALL
HOTSPOTS
 Call
Hotspots
provide
an
estimate
of
how
busy
a
 tm particular
area
is
likely
to
be.
Optima
live 
uses
 historic
call
data
to
calculate
Call
Hotspots
for
 each
hour
of
the
day
and
day
of
the
week.
These
 are
based
on
configured
rules
to
account
for
call
 growth
and
expected
changes
in
call
patterns.
 These
rules
are
used
to
dynamically
calculate
 the
call
hotspots
using
several
years
of
historic
 data
and
the
hotspots
are
updated
as
new
call
 data
is
received.



 The
configuration
allows
the
specification
and
 management
of
special
occasions.
These
are
 times
where
the
call
arrival
rate
is
known
to
be
 atypical
and
should
be
treated
differently.
 Common
examples
include
major
holidays,
such
 as
Christmas
and
New
Year,
or
major
events.


DISPLAY
COVERAGE


THE
VEHICLE
LIST
 The
vehicle
list
shows
all
vehicles
currently
 active
in
 Optima
 tm live ,
along
 with
the
 information
 about
those
 vehicles.
The
vehicle
list
is
displayed
underneath
 the
map
display
windows.

 


tm

Optima
live 
calculates
coverage
and
coverage
 depth
based
on
the
current
state
of
the
system.
 A
location
is
covered
if
an
available
vehicle
can
 reach
that
location
in
the
specified
response
 time.
This
is
not
just
pure
drive
time
but
includes
 other
factors
that
can
significantly
affect
the




142

total
response
time
such
as
known
mobilization
 delays.



appropriate
access
to
review
and
replay
 situations
as
needed.
This
allows:


Coverage
depth
refers
to
the
number
of
vehicles
 tm that
cover
a
location.
Optima
live 
uses
the
 tuned
road
network
to
provide
realistic
 coverage
estimates
that
account
for
time
of
day
 and
day
of
week
variations.
Coverage
is
 indicated
by
blue
shading
and
darker
blue
 indicates
greater
coverage
depth.




Detailed
reviews
of
events,
allowing
 investigation
and
evaluation
of
 performance
including
manual
and
 optimized
deployments
and
dispatch
 decisions




Flexible
control
of
playback,
including
 controlling
the
speed
of
playback
and
going
 directly
to
a
specified
time,
allowing
the
 user
to
focus
on
critical
events


PLAYBACK



Playback
functionality
provides
a
number
of
very
 powerful
benefits:
 •

Playback
can
be
used
to
investigate
 incidents
by
providing
an
immediate
 reconstruction
at
any
given
point
in
time




The
reconstruction
immediately
shows
the
 location
and
status
of
every
active
vehicle
 on
the
graphical
map
display




The
images
from
the
reconstruction
can
be
 captured
and
included
in
incident
reports


tm

Optima
live 
records
the
data
it
receives
from
 the
CAD
system,
allowing
a
user
with


KEY
BENEFITS
OF
OPTIMA
LIVE T M 
REAL
TIME
VIEW
 tm

tm

Optima
live 
real time view
is
primarily
the
enabling
technology
for
the
suite
of
Optima
live 
products.
 tm However,
in
its
own
right
Optima
live 
real time view
provides
some
distinct
benefits:
 •

Powerful
display
gives
users
up
to
date
visual
status
information




The
tuned
road
network
provides
an
accurate
up
to
date
coverage
display




Call
hotspots
show
historic
demand
patterns
specific
to
the
time
of
day,
day
of
week
and
day
 of
the
year




Configurable
to
user
requirements,
with
familiar
color
codes
and
display
icons




143



Optima
livetm
dispatch
 What
would
you
do
to
reduce
response
times
dramatically?
 Managing
communication
centers
for
emergency
services
is
an
incredibly
complex
task.
Dispatchers
deal
 with
hundreds
of
thousands
of
decision
making
permutations
in
their
heads
while
in
reality
the
challenges
 presented
by
juggling
vast
amounts
of
spatial
and
temporal
information
are
difficult
for
the
human
mind
 to
adequately
manage.
 tm

Optima
live 
dispatch
involves
managing
the
 complex
interdependencies
of
your
business
in
a
 time
critical
environment
to
ensure
that
you
 have
the
right
information
at
your
fingertips
to
 make
the
best
decision
there
and
then,
time
 after
time
after
time.
 tm

What
does
Optima
live 
dispatch
do?
 tm

Optima
live 
dispatch
is
a
solution
that
can
 substantially
improve
the
speed
and
accuracy
 for
a
dispatcher
to
make
reliable
assignment
 decisions.
The
underlying
mathematics
of
the
 software
incorporates
relevant
business
rules
 while
considering
all
of
the
variables
that
might
 impact
a
dispatch
decision
and
instantly
delivers
 the
right
solution
to
the
dispatcher
in
a
visually
 rich
way.
This
significantly
reduces
the
“vehicle
 assign”
component
in
the
dispatch
process
while
 delivering
valuable
time
savings
at
the
front
end
 of
the
response
process.
 How
it
works
 Using
Optima’s
Operations
Research
expertise,
 tm Optima
live 
dispatch
has
a
foundation
of
 sophisticated
mathematics
that
considers
the
 following
factors
during
its
calculations:


• • • • • • • • •

Current
road
speeds
 Time
of
day
sensitivity
 Location
of
all
available
vehicles
–
 including
those
that
are
en‐route
to
 another
call
 Lights
&
sirens
travel
speeds
 Available
vehicle
types
 ALS
&
BLS
teams
 Category
of
the
call
 Response
time
compliance
 Predefined
business
rules



All
of
these
factors
are
continuously
recalculated
 in
‘real‐time’
to
ensure
the
recommendations
 provided
to
the
dispatchers
are
accurate,
and
 support
all
operational
business
rules.
The
 recommendations
are
instantaneous,
and,
 providing
the
dispatcher
is
comfortable
with
 these,
they
are
only
a
mouse
click
away
from
 dispatching
the
chosen
vehicles
via
the
 computer
aided
dispatch
(CAD)
system.
Optima
 tm live 
dispatch
will
also
provide
immediate
 alternative
options
to
support
the
dispatchers’
 decision
making
process.


KEY
BENEFITS
OF
OPTIMA
LIVE T M 
 DISPATCH
ARE:
 • • •

Significant
reduction
in
total
response
time
 Prevention
of
dropped
calls
 Knowing
that
the
closest
unit
is
always
 assigned
to
the
highest
priority
incidents




144

TWIN
INTERFACE
 tm

The
Optima
live 
dispatch
interface
provides
the
emergency
communicator
with
two
views
of
the
live
 situation.

 The
first
view
is
the
Real
Time
View;
in
this


then
automatically
provide
a
dispatch
 recommendation
that
is
based
on
the
 predefined
logic
and
current
workload.

 tm

window
the
users
can
see
all
vehicles
across
the
 network,
the
vehicles’
current
status,
call
 coverage
and
areas
of
anticipated
high
call
 demand.



Optima
live 
dispatch
highlights
the
best
 combination
of
resources
to
dispatch
for
the
 incident
type,
factoring
in
their
expected
time
of
 arrival.
The
vehicle(s)
are
identified
in
the
Real
 Time
View
window.


The
second
view
is
the
dispatch
window;
here



 tm

users
can
see
all
calls
waiting
for
dispatch.




Optima
live 
dispatch
also
provides
immediate
 alternative
recommendations
should
the
 dispatcher
need
to
consider
other
options.



The
dispatcher
simply
chooses
a
call
by
selecting
 tm it
for
assignment.
Optima
live 
dispatch
will




145

Clicking
on
the
Confirm
button
pushes
the
 recommended
move
back
to
CAD
and
the
 vehicles
are
immediately
assigned
to
the
call.





146



Optima
livetm
post plan manager
 Optima
livetm
post plan manager
provides
a
Real
Time
 view
of
your
Post
Plan
compliance.
 Consistently
managing
a
coverage
plan
in
real
time
is
a
complex
and
challenging
task
for
dispatchers.
Their
 ability
to
visualize
a
coverage
plan
in
their
minds
to
ensure
comprehensive
real‐time
compliance
is
limited
 and
the
resulting
costs
of
not
doing
so
can
be
significant
to
response
time
performance
and
any
non
 compliance
penalties.
 tm

What
does
Optima
live 
post plan manager
do?
 Leveraging
Optima’s
Operations
Research
 expertise
that
has
been
applied
to
the
suite
of
 tm
 products,
the
Optima
live post plan manager
 enables
users
to
enjoy
visually
rich
information
 to
manage
compliance
against
coverage
plans.
 The
information
provided
allows
the
dispatchers
 to
make
intelligent
deployment
decisions
that
 immediately
improve
coverage
and
compliance.
 How
it
works
 tm


Optima
live post plan manager
has
been
 tuned
to
consider
all
influencing
variables
such
 as
the
real
time
road
speeds,
the
time
of
day,
 travelling
normal
or
lights
and
sirens
speed.
It
 has
also
been
programmed
to
recognize
 historical
call
hotspots
and
uses
AVL
data
to
 determine
the
exact
location
of
every
vehicle.



Finally
it
captures
the
coverage
plan
and
visually
 illustrates
real
time
compliance
along
with
 current
coverage.
 The
posts
are
color
coded
to
show
a
simple
and
 accurate
view
of
compliant
and
non
compliant
 locations.
A
dispatcher
can
see
the
depth
of
 coverage
across
a
given
area
of
responsibility
 and
make
immediate
deployment
decisions
to
 significantly
improve
current
compliance.

 tm


Key
benefits
of
Optima
live 
post plan  manager
are

 • • • • •

Color
coded
compliant
and
non
compliant
 posts
 Current
location
of
all
vehicles
 Geographical
drive
time
coverage
of
all
 available
vehicles
 Hot
spots
of
historical
calls
 Hospitals,
stations
and
posts






147


 tm


The
Optima
live post plan monitor
interface
provides
the
emergency
dispatcher
with
a
view
of
the
 current
status
of
vehicles
and
compliance
to
the
coverage
plan
 The
Real
Time
View
displays
all
current
available
and
assigned
vehicles,
the
current
recommended
posts,
 current
post
assignment
of
each
vehicle
and
the
compliance
to
this
coverage
plan.




 The
color
of
the
circles
identifies
posts
in
compliance
(green),
out
of
compliance
(red)
or
over
compliant
 (blue).
Additionally
if
there
are
alternate
posts
depending
on
type
of
vehicle,
these
share
the
same
 internal
color.
 The
blue
colored
shading
represents
the
depth
of
coverage
(the
darker
the
blue
the
greater
the
depth
of
 coverage),
call
hot
spots
are
in
red
and
the
red
line
identifies
the
assignment
of
a
vehicle.

 tm


As
vehicles
become
available
or
are
assigned
to
calls
Optima
live post plan monitor
dynamically
updates
 the
display
with
the
revised
posting
plan.

 This
enables
the
dispatcher
to
quickly
visualize
the
status
and
enables
deployment
decisions
to
be
made
 efficiently.



POST
PLAN
RECOMMENDER
 Based
on
vehicle
availability,
their
location
and
the
plan
logic,
the
Post
Plan
Compliance
interface
will
also
 recommend
with
an
arrow
which
vehicles
to
deploy
to
which
posts.





148



Optima
livetm
deployment
 Imagine
being
able
to
accurately
improve
your
service
 coverage
twenty
minutes
into
the
future.
 tm

Optima
live 
deployment
improves
your
service
coverage
and
response
times
by
delivering
proactive
 recommendations
to
your
communications
center
regarding
the
best
possible
vehicle
deployments.
Using
 tm built‐in
intelligence,
Optima
live 
deployment
automatically
accounts
for
key
performance
indicators
 such
as
response
time
compliance
and
vehicle
coverage
and
then
displays
all
recommendations
on
an
 easy‐to‐use
interface,
allowing
users
to
make
accurate
and
immediate
deployment
decisions.
 Optima’s
real
time
dynamic
deployment
 solutions
incorporate
predictive
analytics
to
 assist
dispatchers
with
emerging
coverage
 challenges,
while
at
the
same
time
making
 optimized
recommendations
for
unit
 deployment.
 You
cannot
change
what
is
happening
now,
but
 tm with
Optima
live 
deployment
you
can
 influence
what
will
happen
in
the
near
future
 tm

What
does
Optima
live 
deployment
do?
 tm

Optima
live 
deployment
leverages
Optima’s
 extensive
Operations
Research
expertise
and
 uses
sophisticated
mathematics
to
determine
 the
best
locations
to
deploy
the
available
 vehicles.
Based
on
historical
call
demand
and
 tm “Look
Ahead
Technology”,
Optima
live 
 deployment’s
visually
rich
interface
illustrates
 the
future
situation
and
then
recommends
the
 best
possible
moves
to
achieve
maximum
 coverage.

 How
it
works
 tm

Optima
live 
deployment
applies
mathematical
 models
to
real‐time
data
to
present
users
with
 accurate
deployment
recommendations.
How
it
 does
this
can
be
described
in
three
parts.
 Firstly,
in
real
time
it
considers
all
influencing
 variables
such
as
real
time
road
speeds,
the
time


of
day,
directional
differences,
and
lights
and
 sirens
vs
non
lights
and
sirens
speeds
when
 making
a
recommendation.

 Secondly,
it
is
programmed
to
recognize
all
 historical
call
hotspots,
vehicle
types,
required
 response
times
and
it
uses
AVL
plus
Computer
 Aided
Dispatch
(CAD)
data
to
determine
the
 exact
location
and
status
of
every
vehicle.
 Thirdly,
it
captures
the
service’s
complex
 business
rules
and
reviews
all
of
the
historical
 incident
patterns
to
estimate
the
status
and
 location
of
vehicles
in
the
near
future.
This
is
 called
“look‐ahead
technology”.
Additional
 information
considered
in
this
process
includes
 knowledge
of
vehicles
about
to
start
or
finish
 shifts,
clear
scenes
or
hospitals,
or
embark
on
 meal
breaks.
 All
of
these
human
factors
are
blended
with
the
 business
rules
and
fed
to
the
optimizer,
which
 provides
accurate
deployment
 recommendations
to
the
communications
 center.
 tm

Key
benefits
of
Optima
live 
deployment
are:
 • • • • •

Intelligent
support
to
dispatchers
 Accurate
view
of
future
coverage
 Consistent
logical
deployment
recommendations
 No
unnecessary
deployment
moves
 Improved
coverage
–
where
it
is
required




149



Automated

management
of
meal
breaks
 and
shift
changes
 


HOW
IT
WORKS
 There
are
two
user
interface
views
seen
by
the
 communications
centre.



The
look‐ahead
rules
account
for:
 • • • •

Vehicles
starting
and
ending
shifts
 Meal
breaks
 Vehicles
clearing
from
calls
and
returning
to
 their
base
 Realistic
drive‐times
for
vehicles
on
calls,
 driving
to
a
deployment
post,
or
returning
 to
base


LOOK
AHEAD


DEPLOYMENT


The
first
is
the
look‐ahead
mode
which
is
shown
 in
a
split‐screen,
with
the
real‐time
window
on
 the
left
(current
status)
and
the
look‐ahead
 display
on
the
right
(how
the
coverage
will
look
 in
the
future).
This
provides
the
user
with
a
 quick
view
of
how
the
situation
will
change.


The
second
user
interface
view
illustrates
the
 Deployment
mode
and
shows
the
look‐ahead
 display
on
the
left
and
the
deployment
display
 on
the
right.
In
Deployment
mode
the
user
can
 preview
the
impact
of
both
manual
and
 automatic
deployment
moves.
 Deployment
uses
historic
call
patterns
to
 prioritize
where
vehicles
should
be
moved.
The
 recommended
moves
are
constrained
by
highly
 configurable
business
rules
and
include
options
 such
as:
 • • •

Look
ahead
uses
configurable
business
rules
to
 estimate
how
the
current
situation
will
change
 in
the
next
20
minutes
and
then
provides
a
 coverage
plot
based
on
this
estimate
which
is
 illustrated
in
the
right
hand
view


Keeping
vehicles
near
their
home
station
 Returning
vehicles
home
at
the
end
of
their
 shift
and
for
meal
breaks
 Use
different
rules
for
single
response
cars
 rather
than
ambulances
or
any
other
 specialized
resource
type



150



151


 MEAL
MONITOR
 The
Meal
Monitor
provides
users
with
 information
about
meal
breaks,
improving
the
 ability
of
the
service
to
achieve
meal
breaks
and
 reduce
the
costs
associated
with
missed
meal
 breaks.
In
addition,
the
meal
status
can
be
used
 tm by
other
Optima
live 
products.




SHIFT
MANAGER


tm


Optima
live deployment
can
apply
special
 rules
for
the
meal
status,
such
as
ensuring
that
a
 vehicle
due
its
meal
break
is
deployed
to
an
 appropriate
location
to
take
the
meal
break.



Shift
Manager
correctly
matches
active
shifts
to
 tm
 pending
shifts.
This
allows
Optima
live deployment
to
provide
look‐ahead
modeling
of
 shifts
starting
and
finishing
and
to
provide
any
 end
of
shift
rules.


tm


Optima
live dispatch
considers
meal
status
in
 making
dispatch
decisions,
such
as
not
 considering
a
vehicle
due
a
meal
break
for
 response
to
a
low
priority
incident.


tm


Optima
live dispatch
can
use
the
time
until
 end
of
shift
when
making
dispatch
 recommendations,
such
as
excluding
vehicles
 due
to
finish
their
shift
from
responding
to
a
low
 priority
call.








152

153

154

155

156

157

158

Preventative Maintenance Inspection (PMI) Operating Company

Date

Vehicle Number

Cot Number

VIN Number

Stair Chair Number (Last 5 Digits)

Odometer Hours (√ ) Item is Okay ( X ) Repairs are Needed ( O ) Circle X When Repairs are Completed

Type of PMI (Circle One)

A

B

5K

15K

Ground Level Check During PMI Inspections A, B, C Status

Item

Status

Item

Status

Item

Review Unit History

AM / FM Radio

Body Panels / Rust / Paint

Scan - Pull Vehicle Codes

Two Way Radios

Striping and Decals

Road Test - Eng and Trans Run Smooth

Road Safety Speaker

Grille and Hood Condition

Shifter Operation / OD Light

Dome and Map Lights

Antennas

Engine Power - Response

Engine Cover, Latches and Gasket

Running Boards Tight / Secure

Steering Control & Tightness

Emergency Switches and Knobs.

Shoreline Cover

* Steering - (See Spec #1)

Emergency Console Lights and Labels.

Box Rub Rails - Tight / Secure

Brakes - Pedal, Stopping, Pulsation

Siren / PA - Function

AMB Compartment Doors.

Pedal Pads

Handheld Spot Light

Tire Jack and Storage

Test City and Air Horns

Windows and Regulators

Road Safety Spotter Button

* Parking Brake Holds (See Spec #6)

Door Panels and Locks

Pressure Check Coolant System

High Idle Operation.

Door Gaskets and Hinges

Antifreeze Level & Protection______F

Gauges, Warning Lights, Dash Lights

Lube Doors, Hinges, Alignment OK

Antifreeze PH_______(Record 7-9.5)

Wipers, Operation and Washer

Fire Extinguishers 2 ea. 5 lbs.

Engine Oil Level

Mirrors and Glass

Headlights - Hi / Low

Power Steering Fluid Level

Headliner and Visor

Running Lights / Markers /Reflectors

Brake Fluid Level

Registration or Copy

Turn Signals and Hazards

Windshield Washer Fluid

Fuel Card # ____________________

All Brake Lights

ATF Level

Floor mats and Carpet

Back Up Alarm and Light

* Vac Pump Pressure (See Spec #7)

Seat Belts and Seats

License Plate and Lights

Fan Shroud / Upper Radiator

Defrost, Heat, A/C

Emergency Lights and Light Bar

Belt / Tensioner / Idlers (Spec # 10)

Vents and Louvers

Flood Lights

GM / Chevy - Check Ball Joints

A/C Operation _________F Ambient

Scene Lights on with Door Open

* Inspect Lift (Aux Equip guide)

Front_________F

Document Body Damage

*Onboard Gen. (Aux Equip Insp. Guide)

Rear ________F

Check Charging System Status

Item

Status

Item

Status

Item

Up Alt. Output Amps __________

Primary Battery

Secondary Battery

Low Alt. Output Amps __________

# 1 Volts ________ #1 Amps ________

# 1 Volts ________ #1 Amps ________

Starter Draw ___________ (Spec #8)

# 2 Volts ________ #2 Amps ________

# 2 Volts ________ #2 Amps ________

Battery Box & Hold Downs

Visual

Visual

Cables & Connections

Patient Compartment Status

Item

Status

Item

Status

Item

Ceiling, Floor - no wood visible.

Patient Compartment Lighting.

O2 Tanks and Brackets Secured

Cabinets, Walls, Bench no wood visible.

Exhaust Fan

O2 Regulator / Tanks Closed

Upholstery - tight, no rips or cuts.

Onboard Suction, Quick Disconnect

Compressed Air Mounted / Secured

Doors and Latches

Inverter Operation

Air Regulator / Tanks Closed

Cabinet Door Latches Form CO 0021F-00

Lighted 110 VAC Outlet Operation Vehicle PMI Gude Page 1

Antlers - Damage / Secure / Floor Hook

159

Preventative Maintenance Inspection (PMI) Storage Straps and Brackets

Grab Handles

*Inspect Stretcher-use Inspection Guide

Safety Straps, Patient Seat Belts

Sharps Secured

Stretcher Bar / Match / Adjustment Road Safety Spotter Button

Form CO 0021F-00

Vehicle PMI Gude Page 1

160

Gurney Inspection Guide Operating Company

Date Cot Serial

Vehicle Number

AMR # Model Status Codes (NA) Not Applicable (√ ) Item is Okay ( X ) Repairs are Needed

Conducted During Type of PMI (Circle One)

A

B

C

5K

15K

30K

( O ) Circle X When Repairs are Completed

Stretcher Inspection Check During PMI Inspections A, B, C Status

Item Cot unit numbers intact and legible All fasteners secure (Locktite if needed) Welds intact, not cracked or broken No debris in wheels All wheels secure, rolling, and swiveling properly Wheel locks hold wheel securely when on Wheel locks clear wheel when off Base tray secure and in good shape Lubricate base tubes No bent tubing or sheet metal Cot lock bar post tight and secure on lower frame assy Backrest operates properly / Hydraulic cylinder cond. Backrest adjusted properly Breakaway head section operating properly Break away lock and pivot bolt / pin condition Break away release bar condition (not bent) Safety catch bar operating properly (Springs back) Foot rest operating properly IV pole secure and operates properly O2 holder secure and straps in good condition

Status

Item Height positioning latch functioning properly Undercarriage folds properly (No binding) Cot secure in each height position Lock rack and spacers not worn or bent / Return Springs. Side rails move and latch properly Side rails adjusted properly No rips or cracks in mattress cover Velcro in good shape under mattress Restraints present (3 lap belts 2 shoulder harness) Restraints intact and working properly All decals in place and in good shape Paint condition Clean cot (Remove dirt and grime) Cot mounts secure in vehicle (No front to back play) Winch pull points and harness (Bariatric Cot) Winch assembly, cable, and hook (Truck mounted) Inspect Power Cot for Hydro Leaks.

Stair Chair Inspection Check During PMI Inspections A, B, C Status

Item All fasteners secure (Locktite if needed) All welds intact, not cracked or broken No bent tubing or sheet metal No debris in wheels All wheels secure, rolling, and swiveling properly Wheel locks hold wheel securely when on Wheel locks clears wheel when off Chair unfolds and locks properly No rips or cracks in chair seat or back rest Restraints intact and working properly Foot end carrying handles extend and lock properly Head end carrying handles fold and unfold properly Upper control handle extends and locks in all positions

Status

Item Stair-TREAD mechanism unfolds and locks properly Stair-TREAD belt rolls properly Stair-TREAD belt inner cords not showing (Replace) Stair-TREAD performs as desired (Recondition) No lubricants present on Stair-TREAD belts or tracks Upper release cable not worn or frayed (Replace) Optional accessories intact and operating properly All decals in place and in good shape Paint condition Stair Chair securely mounted in unit Chair Make __________________________________ Chair Serial __________________________________

(Notes)

Form CO 0029F-00

Page 1 of 4

161

PMI Guide Equipment Operating Company

Date

Vehicle Number

(NA) Not Applicable

Status Codes ( X ) Repairs are Needed

(√ ) Item is Okay

( O ) Circle X When Repairs Completed

Wheel Chair Lift Check During PMI Inspections A, B, C Status

Item

Comments

Lift Model Overall Condition. Abnormal Noises during operation Lift Control Condition. Securely Mounted and cable tight Lift control cable condition. Secured and not damaged Electrical Wiring. No loose frayed or chaffing wires Decals clearly visible and legible Handrails secure and properly adjusted Lift Mounting and Support points tight and secure Platform Condition Platform operates smooth without obstruction Inner Roll stop operates smooth and lays flat on floor Platform roll stop opens/closes properly at ground level Hydraulic cylinders operate smooth and not leaking Hydraulic Power unit full and no signs of leaks Hydraulic hoses tight and no signs of leaks All safety switches adjusted and operating properly Patient safety restraint condition and operating properly Wheelchair Tie down strap condition Floor track and posts secured tight and condition Seatbelt and shoulder restraint condition Manual lift pump condition and bar present (If equipped)

Emergency Generator Check During PMI A, B, C Status

Item

Status

Item

Status

Item

Check Oil Level

Change Oil and Filter (Syn. Annual)

Check Fan Belt

Check Unit Operation

Check/ Change Air Filter

Check Intake Duct Work

Check Wiring and Routing

Change Fuel Filter (During PMI C)

Check Starter Mounting and Operation

Check Meters, Gauges, and Switches

Drain Water and Sediment from Fuel

Check Alternator Mounting and Operation

Check Output Voltage

Inspect Motor Mounts

Inspect Generator Mounting Hardware

Check Exhaust and Turbo Insulation

Check Engine Protection System

Spark Plug Condition

Check Exhaust and Piping

Run Generator and Check Operation

Spark Plug wire Condition

Check for Fuel Leaks

Check A.C. Voltage AB______ AN______

Check Coolant Level

Check Batt Terminals & Connections

Check Frequency

Test Antifreeze Protection

Clean and Protect Battery Terminals

Start and Stop Unit at Transfer Switch

Inspect Radiator Hoses

Check Battery Voltage

General Inspection of Entire Unit

Inspect Instruments and Gauges

Check Selector Switch

Engine Hours ___________________

Inspect Battery Charger

Start and Stop Unit From Switch

____________

Test Engine Block Heater

Check Exercisor Clock

(Completed by Signature)

Forrm CO 0030-F

Page 1 of 1

162

PMI Guide Equipment Emergency Generator Check During PMI A, B, C Status

Item

Status

Item

Status

Item

Check Oil Level

Change Oil and Filter (Syn. Annual)

Check Fan Belt

Check Unit Operation

Check/ Change Air Filter

Check Intake Duct Work

Check Wiring and Routing

Change Fuel Filter (During PMI C)

Check Starter Mounting and Operation

Check Meters, Gauges, and Switches

Drain Water and Sediment from Fuel

Check Alternator Mounting and Operation

Check Output Voltage

Inspect Motor Mounts

Inspect Generator Mounting Hardware

Check Exhaust and Turbo Insulation

Check Engine Protection System

Spark Plug Condition

Check Exhaust and Piping

Run Generator and Check Operation

Spark Plug wire Condition

Check for Fuel Leaks

Check A.C. Voltage AB______ AN______

Check Coolant Level

Check Batt Terminals & Connections

Check Frequency

Test Antifreeze Protection

Clean and Protect Battery Terminals

Start and Stop Unit at Transfer Switch

Inspect Radiator Hoses

Check Battery Voltage

General Inspection of Entire Unit

Inspect Instruments and Gauges

Check Selector Switch

Engine Hours ___________________

Inspect Battery Charger

Start and Stop Unit From Switch

____________

Test Engine Block Heater

Check Exercisor Clock

Forrm CO 0030-F

Page 1 of 1

163

Investing in Your Success: EMSC Leadership Tools

2009

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Dear Colleague; Great companies are sustained by dedicated employees who are led by great leaders. Great leaders need information and support to serve their direct reports and their stakeholders. This compilation of leadership resources is your tool to easily access the information and support you require. Leading people is a different skill set from being an outstanding EMS professional. Honing leadership talent, gaining leadership skills and knowledge is an ongoing development process. Human Resources and Organizational Development are vested in your success. Warren Bennis, one of the nation’s foremost authorities on leadership said, “The most dangerous leadership myth is that leaders are born - that there is a genetic factor to leadership. This myth asserts that people simply either have certain charismatic qualities or not. That's nonsense; in fact, the opposite is true. Leaders are made rather than born.” It is HR's role to help all of our EMSC leaders by providing the tools and learning experiences needed to be successful. We created this resource to help you easily find opportunities to develop yourself and your team with a wide variety of tools. Use the “Table of Contents” to easily get to the subject you want. If you want to know about the leadership classes the company provides, you will find the “Your Development” section begins on page 2. If you want to learn about staffing start with “Recruiting New Team Members” on page 10. I appreciate your commitment to our company and our team members. I look forward to hearing from you about your successes.

Sincerely,

Kim Norman EMSC Senior Vice President, Human Resources

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Table of Contents YOUR DEVELOPMENT Leadership Orientation………………………………………….…....……...................….1 LEADU DDI Training........................................................................................................1 LEADU Supervisor & Leadership Development Series………………….................…4 EMSC Accelerated Development Program (ADP)………….……………......................4

ANNUAL REQUIRED HR TRAINING Workplace Harassment Prevention and Investigations…..………………..................6 Workplace Violence Prevention…………………………..………………........................6 Affirmative Action……………………………………………………………........................7

RECRUITING NEW TEAM MEMBERS AMR Make a Difference Recruitment Process Version 2.0………………...................8 EMSC Enhance Your Career Kit…………………………………………….…..................8

SELECTING NEW TEAM MEMBERS AMR Paramedic/EMT/Paratransit Wheelchair Driver Selection Process 2.0............10

EmCare Physician Recruiter Selection Process………………….……….…….10 Finding Excellence Recruitment Process Guide………..........................……..11 The Circle of Excellence Process Guide…………………………………....…... 11 EmCare SMD Selection Interview Reference Guide……….……………….…..12 EMSC Billing Process Guide and Pre-Employment Assessment Booklets……………………………………………………………………….…….…12 TEAM DEVELOPMENT AMR/PBS Billing Passport to Success…………………………………….…..…14 AMR Education, Training, and Best Practices Guide……………………….…15

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Table of Contents (continued)

EmCare Recruiter Knowledge Center……………………………………….…...15 EmCare Physician Recruiter Training and Development Kit…………….…..16 SMD Development eLearning Courses………………………….…….…………17 Professional Development Moment (PDM)………………………………….…..17 EMPLOYEE RELATIONS AMR Labor Relations Series………………………………………………….……18 Conducting a Successful Union-Free Campaign………………….…..…….…18 Supervising in a Union Environment I & II………….………….………..………18 Supervising in a Non-Union Environment I & II..……………………….………19 EMPLOYEE RETENTION Years of Service Recognition Programs……………………………….………..20 AMR Stars of Life……………………………………………………….……………20 EmCare Genesis Cup………………………………………..........................…….21 EmCare Commitment to Care………………………….……………...…………..21 Lifeline Award……………………………………………………….…...…………..22 APPENDIX Key Resources and Web Sites………………………………………..….……….23

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Your Development Leadership Orientation: Your local HR professional can arrange for this important orientation. The orientation provides an overview of your development will look in the next couple of years; offers a feel for on-going training required of all leaders; and tells about programs that are available to help recognize and develop your direct reports. You will discover all the tools available to help make recruiting and hiring decisions. This presentation describes how performance appraisals are a tool to help with career development and performance enhancement opportunities. Compensation will reveal itself to be more than determining how much we get paid. Call a member of your HR team today to attend. Training Timeline: All leaders should attend this meeting within six months of promotion or hire. EMSC’s HR Orientation for Leaders

LEADU DDI Training: We have partnered with Development Dimensions International (DDI) - one of the most respected leadership development organizations in the world, to provide a curriculum of nine classes to our leaders. The instructor- led 110 series workshops are designed to be taken first, usually in a day and a half. These are foundation courses for all leaders. The three classes in the instructorled 210 series, also taken in a day and a half, are designed to take the art of leadership to a deeper level by getting strategic. Course materials costs for the 110 and 210 series are approximately $125 each. Your cost center is billed when you attend these workshops. These popular classes are taught by people who live the role; leaders at our company are the facilitators for the courses. A company is serious about leadership development when the leadership is bringing their depth of experience into the classroom.

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Your local HR professional can tell you when the 110 and 210 series are being presented in your area; or contact the NRC Organizational Development department at 702 671-6922. The 910 series are web - based/self - directed leadership classes. Take them at your convenience and at your own pace. You will come away with tools you can use immediately in your role as a leader. The costs for the web based courses are approximately $50 each. Your cost center will be billed when you access each course. Detailed sign- on instructions for the web based courses are outlined in the Appendix.

Leadership

Web link: LEADU DDI Training - Login: Last Name & Last six digits of SSN Password: Last six digits of SSN http://ddiwbt.click2learn.com/aspen/lang-default/SYS_login.asp

EMSC Leadership Foundation Series 110

Essentials of Leadership

Building an Environment of Trust

Resolving Conflict

This foundation course teaches leaders to get results through people. During the course, they gain the tools necessary for a successful “leadership journey.” Learners acquire a set of proven interaction skills, discover seven Leadership Imperatives key to meeting today’s challenges, and realize their roles as a catalyst to inspire others to act. There is a crucial link between trust and business success. Leaders must realize the power of trust as a business tool. Leaders learn how to avoid the trust traps and take action to create an environment in which people take risks, identify and solve problems, and work together to sustain a high level of trust. Leaders will learn how to recognize when a conflict is escalating and minimize the damage by using the most appropriate resolution tactic – regardless of which stage a conflict is in. Leaders also learn the true cost of conflict to an organization and techniques for handling the most challenging conflict related discussion.

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EMSC Strategic Leadership Series 210

Boosting Business Results

Retaining Talent

Making Effective Decisions

In this course leaders learn a proactive strategic process to apply and leverage their leadership skills to realize business objectives. Leaders will identify a project or task that requires the effective use of newly learned leadership skills to achieve or enhance success. Leaders also determine goals and measurement methods that help track and demonstrate the results of their leadership. This course helps leaders understand their critical role in retaining organizational talent. They identify what it takes to keep employees engaged and how to conduct “quick check” discussions for retaining these valuable employees. By taking a proactive approach to retaining people and encouraging open and honest discussion, leaders can create an environment in which people will feel valued and satisfied in their jobs. This course helps leaders master a systemic approach to making better and faster decisions that will result in improved performance.

EMSC Self-Development Series 910 Delegating for Productivity and Growth

To maintain a motivated workforce leaders must become catalysts that transfer responsibility and authority. Leaders learn skills for successfully matching people, responsibility, and authority to maximize involvement, productivity, motivation, and growth for individuals, groups, and the organization.

Interaction Skills for Success

This course presents the basics of working well together, reduce wasted time, lessen conflict, and influence interactions in a positive way. The leader will be able to manage and influence both business and personal interactions.

Adapting to Change

This course develops the confidence and skills needed to face change and welcome it as an opportunity to grow and learn. When employees adapt quickly, the entire organization becomes faster, more flexible, and better able to answer the demands of an increasingly competitive marketplace.

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LEADU Supervisor and Leadership Development Series The most recent version was developed for AMR but the principles are universal and valuable for all leaders, new and seasoned. Each CD is approximately 30 – 45 minutes in length. The LEADU Supervisor 100 CD Series: i i i i i i i i

The History of EMS Your Role as a Supervisor System Status Management and KPI Communications Building Trust Conflict Resolution Performance Management Decision Making

The LEADU Supervisor 101 CD Series: i Financial Accounting i Business Development i Clinical Education Services

i Human Resources i Government Relations i Safety and Risk

LEAD U 100 & 101 & Employment Law Kit Available on ProcureIT AV018 $82.50 EMSC Accelerated Development Program (ADP) The Accelerated Development Program is a company-wide initiative for identifying “high potential” future leaders. This is a very special program; only select leaders are invited to take part in the Accelerated Development Program. In addition to their current responsibilities, ADP participants embark on a development plan to acquire new skills with the goal of becoming great leaders.

Accelerated Development Program

ADP candidates are nominated by other company leaders; either from their direct hierarchy or leaders who have had experience working with and observing them. Nominations are reviewed by a selection panel; final recommendations are sent to the Executive Oversight Committee for consideration and selection. The Executive Oversight Committee also assigns a mentor to each ADP participant who is very involved in monitoring the participant’s progress.

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A brief overview of the ADP process: ¾ Pool members create personal development plans with the goal of completion within 24-36 months ¾ Participation in the pool is voluntary ¾ Employee must continue satisfactory performance ¾ Leaders graduate once they meet all their developmental goals The ADP provides no guarantee of promotion and is not required for promotion. The ADP supplements each division’s and each region’s succession plan. Eligibility requirements for the ADP participation: ¾ At least one year of service ¾ No written corrective action within last 12 months ¾ Exempt employees

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Annual Required HR Training Workplace Harassment Prevention and Investigations Harassment in the workplace is a form of employment discrimination and is prohibited by law. It has been and continues to be our policy that harassment in any form to employees, applicants, vendors, clients and affiliated agencies is unacceptable conduct that will not be tolerated by the company. One of the circumstances outlined in the definition of workplace harassment is a workplace permeated with discriminatory intimidation, ridicule, and insult that is sufficiently severe or pervasive enough to alter the conditions of the victim’s employment and create an abusive working environment and violates Title VII. It is every leader’s responsibility to ensure that we follow EMSC’s policies to ensure a professional and productive work environment.

HOW TO CONDUCT EFFECTIVE INVESTIGATIONS

EMSC National HR Training - Management Version

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The company offers Workplace Harassment Prevention and Conducting Investigations training. Contact your HR professional to determine when the next training is available. Workplace Harassment Prevention Complete Kit Available on ProcureIT, AV020 $75.00

Workplace Violence Prevention We believe in a working environment free from all forms of intimidating or threatening behaviors and we take positive steps to educate employees on violence prevention. FED-OSHA and state counterparts require employers to provide employees with a safe and healthful place to work. Violence in the workplace is a serious safety and health issue. According to the National Crime Victimization Survey, 2 million assaults and threats of violence against Americans at work occur annually. Homicide is the fourth leading cause of fatal occupational injury in the United States. The FBI indicates the most preventable issue is that employers ignore or discount early warning signs.

WORKPLACE VIOLENCE Prevention/Detection Program For EMSC Employees

EMSC National Training

1

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Leaders at our company refresh their knowledge and catch up on new developments in this important area by completing Workplace Violence Prevention training. Training is offered several times a year. Contact your HR professional to determine when the next training is available. Review the Workplace Violence PowerPoint at this web link: http://portal.emsc.net/home/leadership/Training%20and%20Development/F orms/AllItems.aspx Affirmative Action An organization and a profession committed to the preservation and betterment of human life can only be truly effective when the philosophies that have led us to this path are those which guide us through each day. We will maintain our unequivocal commitment to and support of equal employment opportunity for all individuals; free from discrimination based upon gender, race, color, religion, national origin, ancestry, age, physical or mental disability, medical condition, pregnancy, sexual orientation, marital status or any other prohibited biases in accordance with any applicable federal, state or local laws. Our commitment to the highest quality of service must parallel our commitment to the communities we serve. Our dedication to patient care must be mirrored by our dedication to people care. As an organization, we must stand for what is right; and as a team, we must believe in it. All leaders must be familiar with their business Affirmative Action Plan unit’s Affirmative Action Plan and yearly goals. Training for Leaders What is the purpose of our Affirmative Action Plan?

By N. Christopher Comma, Director of HR, EMSC

¾ Analyze the workforce to assess representation of minorities and women; ¾ Develop an action plan to maintain and improve representation of minorities and women; ¾ Analyze personnel decisions to determine if there are selection disparities for minorities or women; ¾ Develop action to ensure no gender or race bias in personnel decisions. Contact your HR professional to determine when the next training is available. Review the Affirmative Action PowerPoint at this web link: http://portal.emsc.net/home/leadership/Affirmative%20Action1/Forms/AllIt ems.aspx 7 174

Recruiting New Team Members AMR Make a Difference Recruitment Process Version 2.0 This resource was designed to provide everything you need to recruit EMS personnel. Finding the right caregivers to join our team is a critical business function, so we’ve put together this toolkit to share best practices, help ensure quality and consistency, and save time. The “clamshell” kit contains: ¾ ¾ ¾ ¾ ¾

The Recruitment Process Guide 2.0 AMR recruitment brochure sample AMR recruitment poster samples A Resource CD The Make A Difference recruitment DVD

The Process Guide clearly lays out the recruiting process, from identifying the ideal EMS professional to planning and executing your recruiting strategy. The DVD describes AMR’s culture and what it is like to be an AMR EMS professional. The DVD is fast-paced and can be set for continuous play; perfect for job fairs, career days and school visits. The CD includes all the recruitment materials, including posters that can be customized with your contact information. If you are looking for additional recruitment materials or ideas, contact your HR professional or Organizational Development. Make a Difference Recruitment Process Version 2.0 Available on ProcureIT, AV001 $39.75 EMSC Enhance Your Career Kit The tool developed to recruit new employees and retain existing ones is the EMSC Enhance Your Career Kit. When employees are looking for career opportunities EMSC understands that pay and health benefits are only part of the puzzle. EMSC and our enterprises

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are located all over the United States, offering mobility and opportunities to our 25,000 employees. Utilize the Enhance Your Career Kit to tell our team members about the programs and services we offer that make us the nationwide employer of choice of EMS professionals. They may be surprised to discover the wide variety of opportunities and programs at their fingertips. ¾ Enhance Your Career PowerPoint This is a modifiable presentation to use at recruitment fairs, school visits or during staff meetings to assist leaders to educate current and future employees of our opportunities and programs. Access the Enhance Your Career PowerPoint from this web link: http://portal.emsc.net/home/leadership/Enhance%20Your%20Career% 20Materials1/Forms/AllItems.aspx ¾ Enhance Your Career Brochure These brochures can be incorporated into your recruitment toolkit or given to employees. Brochures have been created with both an EmCare and AMR cover, but include the same information. Enhance Your Career Kit Available on ProcureIT, Corporate Express 023344CMKT0-1103 $12.33

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Selecting New Team Members EMSC has developed a variety of selection tools to ensure we hire the right employees. Our comprehensive set of selection tools are available for any leader involved in the hiring process. We believe you will find these tools add quality, consistency and efficiency to the selection process. AMR Paramedic/EMT/Paratransit Wheelchair Driver (PWD) Selection Process 2.0 The AMR Paramedic/EMT/PWD Selection Toolkit includes: ¾ Realistic Job Preview DVD o This helps candidates become more interested and committed to the job if it is a good fit, or self-select out if not interested ¾ Updated Practical Skills Exams o Developed in partnership with CES ¾ Updated Structured Interview Questions o Focusing on customer service, stress, and safety AMR Selection Toolkit, 2.0 Available on ProcureIT AV005 $36.00

EmCare Physician Recruiter Selection Process This step- by- step guide provides all the information, forms and processes to follow when hiring a Physician Recruiter, including: ¾ ¾ ¾ ¾ ¾ ¾

Applicant Tracking Telephone Interview Questions Structured Interview Questions Candidate Presentation Prep Team Interview and Reference Checks Forms CD

EmCare Physician Recruiter Selection Process Available on ProcureIT EM002 $30.00

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Finding Excellence Recruitment Process Guide This guide is essential for the successful recruiting of EMS personnel in our client hospitals. Both experienced and new to the role, Physician Recruiters have found this guide instrumental in their success. This guide focuses on best practices in creating strategies for recruiting ED physicians and midlevel practitioners. ¾ Overview of Basic Recruiting Tool o Calling lists, databases, internet, referrals ¾ Targeting Recruiting Audiences o Current ED physicians, EM residents, Grand Rounds ¾ Best Practices o Educational forums, the recruiter and Medical Director relationship, building trust ¾ Overcoming Obstacles Finding Excellence Recruitment Process Guide Available on ProcureIT, EM003 $16.75 The Circle of Excellence EMSC Billing Recruitment Process Guide While developed for leaders of the Billing organization, this tool is useful to everyone recruiting. From the “Can Do – Will Do” model, to the advice on how and where to place ads, this guide offers a wealth of information that will lead to successful new employees. The Circle of Excellence Process Guide includes: ¾ ¾ ¾ ¾

An Overview of the Recruitment Process The Ideal EMSC Billing professional Recruitment Strategies Advertising, writing ads, career fairs, open houses, and recruiting a diverse workforce

Billing Recruitment support materials include: ¾ The EMSC Billing Recruitment Brochure ¾ The EMSC Recruitment Video (DVD) The Circle of Excellence Process Guide and DVD Available on ProcureIT, EM008 $19.50

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EmCare SMD Selection Interview Reference Guide Selection of the Emergency Department Medical Director is critical for our success. This guide is designed to be used by both experienced and new interviewers to support regional practices for selecting site medical directors. The guide is tabbed to allow quick reference information on: ¾ The purpose of the structured interview ¾ Suggested interview questions ¾ A suggested outline to follow when considering one candidate ¾ A suggested outline to follow when considering multiple candidates ¾ Evaluating candidates and ratings errors Experienced interviewers may want to occasionally review; new or first time interviewers will want to read the guide before the first interview is arranged. Access the SMD Selection Interview Reference Guide at this web link: http://portal.emsc.net/home/leadership/default.aspx

EMSC Billing Process Guide and Pre-Employment Assessment Booklets After following the path laid out in The Circle of Excellence EMSC Billing Recruitment Process Guide you are ready to interview and select your successful billing employees. The EMSC Billing Process Guide contains several booklets that cover all the facets of the pre-and post-interview process. The Structured Interview booklet includes questions in key billing skill areas such as: ¾ ¾ ¾ ¾ ¾ ¾

Task Management Problem Solving Following Directions Interpersonal Skills Customer Service Professionalism

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The Pre-Employment Assessment Booklets are laminated, reusable test booklets and answer sheets designed to assess competency for a variety of positions, including: x x x x x x x x x x x x

Insurance Inquiry Rep A/R Follow Up Rep Coding Analyst I and II Patient Services Rep Bilingual Patient Services Rep Correspondence Rep Document Prep Posting/Suspend Rep Insurance Verification Rep Imaging Processor Work Flow Rep Clerk Positions

The Test Administration Guide provides step-by-step instructions for proctors on how to implement and score these assessments.

EMSC Billing Process Guide and Pre-Employment Assessment Booklets Available on ProcureIT, EM004 $96.00

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Team Development AMR/PBS Billing Passport to Success Passport to Success is a career growth program designed to help employees prepare themselves to take on new roles in the organization. In employee opinion surveys, team members have told us they are interested in establishing a career with our company, but don’t always know what opportunities exist. This is an opportunity for them to explore additional career paths and enhance their skills for advancement. Participant Eligibility Requirements: At least six months in current position Have supervisor’s approval to participate Be able to travel if needed for learning experiences necessary or relevant to Passport activities ¾ Be continually self-motivated to complete Passport activities ¾ ¾ ¾

Organizational Development is in the process of developing new Passports in addition to those currently available for employees in the following areas: ¾ ¾ ¾ ¾ ¾ ¾ ¾ ¾ ¾ ¾

Business Development Compliance Clinical & Education Services Dispatch Accounting Fleet Services Human Resources Information Technology Operations Billing

Who do I talk to? To learn more about the Passport to Success Program contact your manager, your HR professional, or access the web link: www.amrlearning.com/passport

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AMR Education, Training and Best Practices Guide The AMR Education, Training and Best Practices Guide is your resource for learning more about supporting educational programs for potential and current employees, including: ¾ ¾ ¾ ¾ ¾ ¾

Employee Loan Programs Employee Scholarship Programs Tuition Reimbursement Programs Benefit Retention Programs State Grants Community College Fund Share Programs

The guide also contains samples and templates you can use when developing educational assistance programs at your location. Access the AMR Education, Training and Best Practices Guide at this web link: http://portal.emsc.net/home/leadership/Retention/Forms/AllItems.aspx

EmCare Recruiter Knowledge Center Designed for Physician Recruiters, this site is also a great resource for all leaders involved in the hiring and placement of physicians and mid-level clinicians; or anybody impacted by staffing and scheduling. The Knowledge Center contains ideas for addressing the most common questions and challenges faced by Physician Recruiters broken down into these categories: ¾ ¾ ¾ ¾

Contracts Advertising and Sourcing Recruiting and Finding the Match Relationship Building

Click on a question and see video of a Physician Recruiter subject-matterexpert sharing information and expertise. The Knowledge Center is also searchable by key words and questions. Answers can be printed out in hardcopy. 15 182

The Knowledge Center web link is: http://emcare.avatarknowledgecenter.com/ This is a password protected site; the sign-on is emcare and the password is 1717main. EmCare Physician Recruiter Training and Development Kit This self-paced resource prepares newly hired Physician Recruiters to hit the ground running. Seven CDs and a participant workbook guide new Physician Recruiters through all aspects of their new job. The program offers realistic scenarios and exercises that new recruiters can discuss with their managers and peers to gain deeper insight into what it takes to recruit the best for our company. The CDs and participant workbook cover the following areas: ¾ Course 1: The EmCare Opportunity ¾ Course 2: Our Target Customers ¾ Course 3: The Recruiting Process o Part 1: Connecting with the Candidate o Part 2: Generating Interest o Part 3: Presenting the Candidate o Part 4: Closing ¾ Course 4: Time Management

EmCare Physician Recruiter Training and Development Kit Available on ProcureIT, EM001 $70.00

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SMD Development eLearning Courses Emergency Department Medical Directors can raise the level of their leadership knowledge by accessing the leadership development courses created especially for them. Understanding your Role, Managing Conflict and Managing Up address many of the challenges unique to leading an emergency department. The courses are housed in EMEDS and can be accessed at this web link: http://www.emedsinc.com/_emcare/default.cfm?fn=XXXX&ln=hbtest&ssn=& [email protected]@9956tGiUttRlseP334Fgbvv

Professional Development Moment (PDM) Each month we send an e-mail to leadership team members known as the Professional Development Moment or PDM. Each PDM covers a topic of interest to leaders. Recent PDM subjects have included; coaching, public speaking, workplace violence prevention, delegation, and explanations of a variety of company programs. Keep your eye out for the monthly PDMs as they contain timely information that can be used immediately. If you are not receiving PDMs, call Organizational Development at 702 671-6922 to be added to the leadership distribution list. You can view PDMs at this web link. http://portal.emsc.net/home/leadership/Professional%20Development%20Mi nutes/Forms/AllItems.aspx

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Employee Relations AMR Labor Relations Series The AMR Labor Relations Process was created to improve all aspects of labor relations within AMR, regardless of a union's presence. Our goal is to create a fair environment in which we may enjoy a direct oneon-one relationship with each of our valued employees. The Labor Relation Series is a combination of CDs, workbooks and job aides aimed at preparing leaders for various types of labor issues. Conducting a Successful Union Free Campaign As the title implies, the materials in this set are designed to be used during or when there is the possibility of a union campaign. ¾ ¾ ¾ ¾ ¾ ¾

Conducting a Successful Campaign - Self Directed CD ROM Course Conducting a Successful Campaign - Process Guide Did You Know? - DVD Did You Know? - Campaign Meeting Handout Questions & Answers - Campaign Meeting Handout What If & What to Do - Supervisor’s Job Aid

Conducting a Successful Union Free Campaign Available on ProcureIT AV059 $35.00

Supervising in a Union Environment I & II Supervising union employees can be a unique and rewarding challenge. The way in which you interpret and administer the collective bargaining agreement and adhere to federal laws can drastically affect the morale of your staff and AMR's legal status. One of your primary responsibilities as a leader in a union environment is to create procedural fairness by following the collective bargaining agreement, federal and/or state laws. Use this guide in conjunction with the two- CD course Supervising Union Employees to help you make good decisions with ease and remain within your legal boundaries.

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Supervising in a Non-Union Environment I & II At EMSC, we believe our employees are our greatest strength. We know that their daily decisions are the foundation for our success, and that's why we take the time to support each of them through productive one-on-one relationships. We know that when our relationships with our employees are limited, our growth is limited. As an EMSC leader, you have a great deal of authority to affect the morale of your employees every day. With every decision you make, you can create a fair or an unfair environment for them. When employees know that they are valued and treated fairly, they are more likely to work up to their potential and less likely to seek unionization as a means to achieving fairness. All AMR employees hired or promoted into the leadership ranks must complete the courses within six months of promotion or hire. If you have any questions or need additional supplies, please contact your HR professional. Supervising in a Union Environment I & II Supervising in a Non-Union Environment I & II Self-directed CD-ROM courses with Personal Process Guides Available on ProcureIT AV059 $35.00

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Employee Retention Years of Service Recognition Programs Showing appreciation for employee loyalty and dedication is very important to all EMSC, AASI, AMR, EmCare and RTI leaders. The Years of Service recognition program was created to express this appreciation to employees at important milestones in their career with our company. As important as this celebration is, not everyone takes advantage of the program. The Years of Service program recognizes employees’ important milestones linked to their hire date. All business segments celebrate Years of Service milestones in their own unique way. In most EMSC companies, beginning with the fifth anniversary and every five years after, employees are given the opportunity to select an anniversary gift from a catalog mailed to their home. The catalogs have a wide selection of gifts; jewelry, electronics, homes furnishings, sports equipment, outdoor items and more. Within days of making their selection, the chosen gift is delivered to the employee’s home. It is so easy! All leaders need to do is: ¾ Make sure your e-mail address is correct in Oracle so you will get reminder e-mails from our Years of Service program vendor; ¾ Be on the lookout for a presentation box with the employee’s name and anniversary year delivered during the month of the anniversary; ¾ Plan how to celebrate! Deliver that presentation box yourself; thank the employee for their service! If there is a concern in this process, contact the Organizational Development Department. They will be happy to help resolve any problems or answer any questions you have with the process or the program. AMR Stars of Life The Stars of Life program offers a unique opportunity for AMR to bring national recognition to our employees and to our company. Full-time paramedics, EMTs, communication center employees and other front-line professionals who meet the selection criteria may be nominated as an AMR Star of Life. The qualities and achievements for which the Stars of Life are selected are consistent with AMR’s Mission, Vision and Core Values.

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The Stars of Life program honors these individuals as representatives and ambassadors of our industry so that local communities and government agencies are given the opportunity to honor the contribution they make to our nation every day. This is a time for all of us to stand proud of what we do and to applaud those who set examples for all of us. View this event as not only a forum for communicating your appreciation for your employees but also as a way for the world to recognize the value of our industry.

EmCare Genesis Cup The Genesis Cup Award recognizes the creativity and innovation of our physicians in the never- ending pursuit to improve the delivery of patient care in our emergency departments. The cup recognizes and is engraved with all members of the team including Administration, ED Nurses, ED Techs, ED CNA's, ED Unit Coordinators, Registration, Radiology and Laboratory Services. It is awarded at the EmCare Medical Directors Conference.

EmCare Commitment to Care The Commitment to Care award recognizes outstanding emergency medicine physicians whose contributions are felt in the hospitals in which they work, in their communities and the country. The award program serves as an extension of EmCare’s efforts to lead the industry in quality service and provide career opportunities for top physicians. Nominations are accepted from physicians across the country wishing to recognize their colleagues for outstanding service. A committee comprised of physician leaders reviews all of the nominations submitted and selects the winner. This award is presented to an individual who represents and exemplifies the mission and values of EmCare physicians; whose work and daily life reflect our core values of Patient Care, Compassion, Community and Collaboration.

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Lifeline Award The Lifeline Award Program at RTI and EmCare exists to honor employees who perform above and beyond the call of duty. Those employees who exemplify one or more of the following character traits are nominated by their peers and recognized by the company. ¾ Leadership ¾ Integrity ¾ Teamwork ¾ Quality ¾ Initiative ¾ Productivity The outstanding performance of our employees is the "Lifeline" to achievement and leadership in emergency medicine practice management.

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APPENDIX Key Resources & Web Sites Human Resources – National Resource Center:

303 495-1437

Organizational Development – National: 702 671-6922 Leadership Development Years of Service Passport to Success Accelerated Development Program

EMSC Portal http: http://portal.emsc.net/home/default.aspx Passport to Success: http://www.amrlearning.com/passport/ ProcureIT: http://procure.amr.net Employee Resources: http://portal.emsc.net/home/empresources/default.aspx Human Resources Commonly Used Forms: http://portal.emsc.net/home/leadership/HR%20Commonly%20Used%20 Forms/Forms/AllItems.aspx

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HUMAN RESOURCES DEPARTMENT Pre-Employment Standards The intent of this policy is to establish a standard by which the driving records of applicants for all positions which require driving may be judged. Applicants who do not meet these standards will be considered ineligible for hire in accordance with company policy. All applicants for positions which require driving must be at least eighteen (18) years old with a driving record that falls within the parameters outlined below. Applicants for positions which require driving will be considered ineligible for hire if their driving record contains convictions for any of the following within the preceding 36 months as measured from the date of citation. It is the applicant's responsibility to provide a current copy (no older than 3 weeks) of their DMV record. 1. DUI, open alcohol container, violation of implied consent, in physical control or any other alcohol or drug related offense. 2. Hit and Run or Leaving the scene of an accident. 3. Greater than one at fault accident. 4. Greater than one moving violation. 5. Combination of one at fault accident and one moving violation (exclusive of a violation related to the at fault accident). 6. Currently suspended license even if the suspension does not apply to employment usage. 7. Driving with a suspended license. 8. Reckless or careless driving. 9. Speed contest or exhibition of speed. 10. A record which evidences disregard for the law. More than two non-moving violations (FTA, FTP, Financial Responsibility, Expired License, etc.) or one moving and two nonmoving violations. (FTAs shall apply even if they have subsequently been resolved.) Candidates will be considered ineligible for hire if their record contains conviction(s) of: 1. 2. 4.

5. 6.

Any offense punishable as a felony or conviction of any theft within the preceding seven years. Any act involving moral turpitude, including fraud or intentional dishonesty for personal gain within the preceding seven years. Within the preceding seven years, any offense relating to the use, sale, possession, or transportation of narcotics or addictive or dangerous drugs, or of any crime involving force, violence, threat, or intimidation. (Marijuana convictions past two years can not be held against them.) Is on probation to DMV for a cause involving the unsafe operation of a motor vehicle. Within the preceding three years, has had driver's license suspended or revoked for a cause involving the unsafe operation of a motor vehicle.

Candidates will be considered ineligible for hire if their record contains convictions of any of the following at any time. 1. 2. 3.

Use of vehicle in a felony. Flee or eluding a police officer. If the candidate is required to register as a sex offender under Section 290 PC for any offense involving force, violence, threat, or intimidation.

H:\Employment\PreEmpStandards.rtf

Rev. 01/01

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Info Cubic

9250 E Costilla Ave. Suite 230 Greenwood Village, CO 80112 Phone: 1-877-360-4636 Fax: 1-303-220-0171 Email: [email protected]

Info Cubic Sample Report Denver, CO 80111 Phone: 303-220-0170 Email: [email protected]

Profile Information Name: SSN: DOB:

John Smith 123-45-**** 01/01/****

The following are included in this report: Search Type

Detail

Status

Instant SSN Trace

Complete

Education Verification

America High School

Complete

Education Verification

University of Colorado - Boulder

Complete

Employment Verification

ABC Company

Complete

123 Company

Complete

Employment Verification Motor Vehicle Records Search

California (license 123456789)

Complete

OIG & GSA Excluded Party/FACIS Search

Complete

Patriot Act/OFAC/BXA/Terrorist list Search

Complete

County Criminal Records

Ventura, California

Complete-No Record

Instant Criminal Database Search

US OneSEARCH

Complete- No Record

Background Check Notification

Complete

Instant SSN Trace Social Security Number Name DOB Search ID Date Ordered Date Completed Results

123-45-**** John Smith 01/01/**** 798 06/28/2009 06/28/2009

Smith, John (DOB: March, 1967) (SSN: 360-52-****) Address 1 1234 COSTILLA AVE OXNARD CA 93035 -3742

 

Address 2 1234 AMINTA AVE THOUSAND OAKS CA 91360 -2033

Info Cubic. LLC. A Nationwide Employment and Tenant Screening Company 9250 E Costilla Ave. Suite 230 Greenwood Village, CO 80112 Toll Free: 1-877-360-INFO (4636) FAX: 303-220-0171 

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Info is Power County: VENTURA CA Date first reported: June, 2004 Date last reported: September, 2009

County: VENTURA CA Date first reported: October, 2009 Date last reported: December, 2009 Address 3 1234 MAIN STREET APT 123 SIMI VALLEY CA 93065 -0434 County: VENTURA CA Date first reported: January, 2006 Date last reported: August, 2006

 

Education Verification Name Searched

John Smith

DOB

01/01/****

SSN

123-45-****

Search ID

70596

Reference

07/15/2009

Date Ordered

07/15/2009

Date Completed Status Information Provided School

Complete John Smith America High School

Degree

Diploma

Location

Thousand Oaks, CA

Information Searched School Location Information Verified Degree

America High school Thousand Oaks, CA Diploma

06/12/2003 Graduation Date Comments The information above was verified by Jane Doe, Registrar, on July 15th, 2009. She verified that John Smith was a full time student and graduated on June 12, 2003.

Education Verification Name Searched

John Smith

DOB

01/01/****

SSN

123-45-****

Search ID

70597

Date Ordered

07/15/2009

Date Completed

07/15/2009

Status

Complete

Information Provided School

CU

 

Info Cubic. LLC. A Nationwide Employment and Tenant Screening Company 9250 E Costilla Ave. Suite 230 Greenwood Village, CO 80112 Toll Free: 1-877-360-INFO (4636) FAX: 303-220-0171 

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Info is Power Degree

BA

Major

Economics

Graduation Date

2000

Information Searched School

University of Colorado at Boulder Boulder, CO

Location Information Verified Degree

Bachelor of Arts

Major

Economics with a Minor in Business Administration

Start Date

08/25/1997

End Date

12/21/2001

Graduation Date

12/21/2001

GPA Comments

Not Available

The information above was verified by The National Student Clearinghouse on July 15, 2009. The automated system verified that John Smith was a full time student that graduated on December 21, 2001 with a Bachelor of Arts degree in Economics and a Minor in Business Administration. Transaction ID: 000000000

Employment Verification Name Searched

John Smith

DOB

01/01/****

SSN

123-45-****

Search ID

70595

Reference

07/15/2009

Date Ordered

07/15/2009

Date Completed

Complete

Status

John Smith

Information Provided Company

123 Company

Company Phone

(805) 123-4567

Company Location

City, CA

Company Contact

Don Vitas

Position Held

Server

Salary

15/hr

Start Date

7/08

End Date

Current

Information Searched Company

123 Company

Company Phone

(805) 123-4567

Company Location

City, CA

Source Contacted

Jane Brown

Information Verified Position Verified Server Start Date

 

07/2008

Info Cubic. LLC. A Nationwide Employment and Tenant Screening Company 9250 E Costilla Ave. Suite 230 Greenwood Village, CO 80112 Toll Free: 1-877-360-INFO (4636) FAX: 303-220-0171 

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Info is Power End Date

Current

Additional Comments The information above was verified by Jane Brown, CFO, on December 1, 2009. She verified that John Smith is a part time employee as a Server.

Employment Verification Name Searched

John Smith

DOB

01/01/****

SSN

123-45-****

Search ID

1288

Date Ordered

06/28/2009

Date Completed

07/02/2009

Status

Complete

Information Provided Company

ABC Company

Company Phone

(800) 111-1111

Company Location

Hollywood, CA

Company Contact

Doug Jones

Position Held

Sales Rep

Start Date

09/00

End Date

10/05

Information Searched Company

ABC Company

Company Phone

(800) 111-1111

Company Location

Hollywood, CA

Source Contacted

John Jones

Information Verified Position Verified

Sales Rep

Start Date

09/10/2000

End Date Answers to Standard Questions Attendance

10/05/2005 Excellent

Eligibility for Rehire

Yes

Works well with Others

Definitely

Work Habits

Good

Written/Communication Skills

Fair

Disciplinary Action

Never

Overall Performance(1-10:best)

9

Reason for Leaving

Voluntary Departure

Additional Comments: Spoke with Doug Jones, Manager, who provided this information. He stated that Mr. Smith was a very good employee and will be missed greatly. He was very good at sales and earned a reputation for going above and beyond the call of duty. No further information was provided.

 

Info Cubic. LLC. A Nationwide Employment and Tenant Screening Company 9250 E Costilla Ave. Suite 230 Greenwood Village, CO 80112 Toll Free: 1-877-360-INFO (4636) FAX: 303-220-0171 

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Motor Vehicle Records Search State

Colorado

License

123456789

Name Searched

John Smith

DOB Searched

01/01/****

SSN Searched

123-45-****

Search ID

69670

Date Ordered

06/28/2009

Date Completed

06/28/2009

Results

California driving record report Reference ID: LICENSEE NAME/ADDRESS SMITH, JOHN B 12345 MAIN ST Ventura Ca LICENSE NUMBER D.O.B. 123456789 01/01/**** CLASS ADULT REGULAR LICENSE STATUS VALID

ORIG.ISSUED

BOATCLASS

REINST DATE

PRIOR STATE

SECONDARY LIC.

01/11/2008 02:53:57 PM Report requested on: 01/11/2008 Account # 85027 REPORT PREPARED FOR INFO CUBIC LLC 9250 E COSTILLA AVE STE 230 GREENWOOD VILLAGE, CO. 80112 SEX HGT WGT EYES HAIR RACE SOC.SEC M 606 190 BLUE BRO ISSUED 04/07/2006

EXPIRES 02/01/2011

RESTRICTIONS CORRECTIVE LENSES

NON-RESIDENT MILITARY

LIC TYPE ADULT REGULAR LICENSE

ENDORSEMENTS **NONE**

PRIOR DL# PRIOR DL STATUS

DONOR Y

C.D.L.ISSUED

OTHER STATE LIC.

POINTS C.D.L.STATUS NOT APPLICABLE OTHER STATE

MISCELLANEOUS AND STATE SPECIFIC INFORMATION Approximate Year of Original Issued: 2000 H - Health Questionnaire Renewal By Mail Status: RBM1 - First Renewal By Mail DRIVING RECORD HISTORY ACCI 02/20/2008

California accident, reported by CHP County/Location.....: CAMARILLO Miscellaneous.......: Record Updated Date: 09/08/2008 Event Type..........: ACCIDENT State Code..........: D Veh. License........: 123456 FR Report #.........: 123456789 Accident Report.....: 12345678910 ACD Code............: AAA

** END OF RECORD **

OIG & GSA Excluded Party/FACIS Search Name Searched

 

John Smith

Info Cubic. LLC. A Nationwide Employment and Tenant Screening Company 9250 E Costilla Ave. Suite 230 Greenwood Village, CO 80112 Toll Free: 1-877-360-INFO (4636) FAX: 303-220-0171 

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DOB

01/01/****

SSN

123-45-****

Search ID

156881

Date Ordered

06/28/2009

Date Completed

06/29/2009

Results No records were found matching your search request.

Patriot Act/OFAC/BXA/Terrorist list Search Name Searched

John Smith

DOB

01/01/****

SSN

123-45-****

Search ID

54654

Reference Date Ordered

07/30/2009

Date Completed

07/30/2009

Results No Matches Found

County Criminal Records Jurisdiction Searched

Ventura, California

Name Searched

John Smith

DOB Searched

05/27/****

SSN Searched

152-66-****

Search ID

259157

Date Ordered

07/29/2009

Date Completed

07/30/2009

Number of years searched

7

Status

No Records Found

Instant Criminal Database Search Name Searched

John Smith

DOB

01/01/****

SSN

123-45-****

Search ID

111111

Reference

6110

Date Ordered

07/31/2009

Date Completed

07/31/2009 8:52 AM

 

Info Cubic. LLC. A Nationwide Employment and Tenant Screening Company 9250 E Costilla Ave. Suite 230 Greenwood Village, CO 80112 Toll Free: 1-877-360-INFO (4636) FAX: 303-220-0171 

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Results No Records Found Jurisdiction Searched

US OneSEARCH

AK Proprietary Offender Data,AK AOC,AK Sex Offender,AL DOC,AL Proprietary Offender Data,AL Sex Offender,AR AOC,AR Proprietary Offender Data,AR DOC,AR Sex Offender,AR Sex Offender,AZ Maricopa Superior Archive,AZ Maricopa Felony,AZ Maricopa Misdemeanor,AZ AOC,AZ Pima,Maricopa County Superior Court,AZ Mohave,AZ DOC,AZ Proprietary Offender Data,Manually Collected Data,AZ Maricopa Superior,AZ Sex Offender,CA Alameda County,CA Butte County, CA,CA Contra Costa Muni Court,CA Contra Costa Superior Court,CA Indio City County,CA Marin - Municipal,CA San Diego - Municipal Court,CA San Diego - Superior Court,CA San Luis County,CA Ventura County,CA San Mateo County,CA Marin - Superior Court,CA San Diego Superior Court,CA Stanislaus,CA Ventura Superior Court,CA Fresno Index,CA Orange,CA Sacramento,CA Riverside,CA Los Angeles,CA Santa Clara,CA San Bernardino,CA Santa Barbara,CA Santa Cruz,CA Proprietary Offender Data,CA Sex Offender,CO Proprietary Offender Data,CO DOC,CO Sex Offender,CT Judicial Information System,CT Judicial (Traffic Data),CT DOC,CT DOC,CT Proprietary Offender Data,Manually Collected Data,CT Sex Offender,CT Out of State Sex Offender,DC DOC,DC Proprietary Offender Data,DC Sex Offender,DE Proprietary Offender Data,DE Sex Offender,FL Pinellas,FL DOC,FL AOC,Indian River FL,Lee County Sheriffs Office,Pasco County, FL Crim Data,Monroe County FL Clerk Circuit,FL Osceola,FL Miami Dade,FL Volusia,FL DOC,FL Brevard,FL Charlotte,FL Orange,Seminole County, FL Crim,FL Bay,FL Duval,FL Hillsborough,FL Highlands,Manatee, FL Criminal Data,Miami-Dade County,FL Crim Data,FL Okaloosa,FL Palm Beach,Palm Beach FL Felony data,Palm Beach FL Misdemeanor Data,FL Proprietary Offender Data,FL Hernando,Monroe County, FL Arrest Recs,FL Suwannee,FL Alachua,FL Broward,FL Putnam,FL Putnam Traffic,FL Sex Offender,FL Sex Offender,GA DOC,GA Parole Data,GA Bureau of Investigations,GA Proprietary Offender Data,GA Decatur Arrest Records,GA Sex Offender,GU Proprietary Offender Data,GU Sex Offender,HI Proprietary Offender Data,Hawaii AOC,HI Sex Offender,IA DOC,IA AOC,IA Proprietary Offender Data,IA Sex Offender,ID DOC,ID Proprietary Offender Data,ID Sex Offender,IL DOC,IL Cook,Peoria County Treasurer,IL Sangamon,IL Proprietary Offender Data,Manually Collected Data,IL Sex Offender,IN Proprietary Offender Data,IN DOC,IN Sex Offender Sheriff,KS DOC,KS Proprietary Offender Data,KS Sedgwick,KS Sedgwick Archive,KS Sex Offender,KY DOC,KY Proprietary Offender Data,KY Lexington Fayette Div.,KY Sex Offender,LA Proprietary Offender Data,Manually Collected Data,LA DOC Parole,LA Sex Offender,Boston PD Booking Reports,MA Proprietary Offender Data,MA Arrest (Limited),MA Court (Limited),Connecticut,Manually Collected Data,MA Sex Offender,MD DOC,MD Proprietary Offender Data,MD Sex Offender,ME DOC,ME Proprietary Offender Data,ME Sex Offender,MI DOC,MI OTIS,MI Proprietary Offender Data,MI Wayne,MI Sex Offender,MN DOC,MN DPS,MN Proprietary Offender Data,MN Sex Offender,MO DOC,MO Proprietary Offender Data,MO AOC,MO Sex Offender,MO Cape Girard Sex Offender,MO Cole Sex Offender,MO Barton Sex Offender,MO Jefferson Sex Offender,MO Newton Sex Offender,MO Laclede Sex Offender,MO St. Louis Sex Offender,MS Hinds,MS DOC,MS Proprietary Offender Data,MS Harrison Circuit Court,MS Sex Offender,MT DOC,MT Proprietary Offender Data,MT Sex Offender,NC AOC,NC Proprietary Offender Data,NC DOC,NC Sex Offender AOC,NC Sex Offender,ND AOC,ND Proprietary Offender Data,ND Supreme Court,ND Sex Offender AOC,ND Sex Offender,NE Proprietary Offender Data,NE DOC,NE Sex Offender,NH DOC,NHDOC,NH DOC,NH Proprietary Offender Data,NH Sex Offender,NJ AOC,NJ DOC,NJ Proprietary Offender Data,NJ Archive DOC,NJ Sex Offender,NM DOC,NM Proprietary Offender Data,NM Sex Offender,NV Proprietary Offender Data,NV Archive DOC,NV DOC,NV Sex Offender,NY DOC,NY Proprietary Offender Data,NY Sex Offender,AppAlert Federal Criminal Data,AppAlert OFAC,OH Clinton,OH Sidney Municipal Court,OH Portage,OH Hamilton,OH Greene,OH Avon Lake,OH Euclid,OH Gallipolis,OH Hardin,OH Lawrence,OH Lebanon,OH Lakewood,OH Canton,OH Bedford,OH Belmont - Northern Division,OH Berea,OH Chardon,OH Alliance,Akron Municipal Court, OH Crim,OH Lorain,OH Ashtabula,OH Montgomery,OH Elyria,OH Hancock,OH Garfield Heights,OH Guernsey,OH Allen,E. Cleveland, OH Court Crim,Lima Municipal Court, OH Crim,OH Massillon,Medina County, OH Court Crim,OH Mentor,OH Parma,OH Shaker Heights,OH Rocky River Municipal,OH Putnam Common Pleas,OH Putnam County,OH Sylvania,Vermilion Municipal Court, OH,OH Tuscarawas,OH Xenia,OH Wood,OH DOC,OH Dayton,OH Butler,OH Proprietary Offender Data,OH Sex Offender,OK AOC Criminal Data,OK DOC,OK Proprietary Offender Data,OK AOC OSCN,OK Sex Offender,OR DOC,OR Proprietary Offender Data,OR AOC,OR Sex Offender,OR Multnomah County SOR,OR Web Sex Offender Registry,PA AOC Supplemental,Pennsylvania AOC Traffic,PA DOC,PA Proprietary Offender Data,Philadelphia PA AOPC,PA CPCMS Criminal Data,PA AOC,PA Sex Offender,PR Proprietary Offender Data,PR Sex Offender,RI Judicial Technology Center,RI DOC,RI Proprietary Offender Data,RI Sex Offender,SC DOC,SC Proprietary Offender Data,SC Sex Offender,York SC Sex Offender,SD Proprietary Offender Data,SD Sex Offender,SD Aberdeen Sex Offender,SD Sioux Falls Sex Offender,TN DOC,TN Davidson Sheriff,TN JIS Criminal Database,Rutherford, TN Circuit Crim,Rutherford, TN Gen Sessions,TN AOC,TN Nashville,TN Proprietary Offender Data,TN Sex Offender,TX Bexar Misdemeanor,TX Bexar Felony,TX Travis Misdemeanor,TX Travis Felony,Victoria, TX Criminal,Brazoria, TX Criminal,TX Ft. Bend Felony,TX Ft. Bend Misdemeanor,TX Jefferson District,TX Montgomery,TX Potter Misdemeanor,TX Potter Felony,TX Denton,TX El Paso,TX Harris Felony,TX Harris Misdemeanor,TX Smith,TX Dallas,Midland County, TX Criminal,TX Proprietary Offender Data,TX Gregg,TX Jefferson,TX Dept of Public Safety,Collin County, TX Court Crim,Collin District, TX Court Crim,Collin TX Traffic,TX Waller Circuit Court,TX Williamson County Court,TX Sex Offender,UT DOC,UT AOC,UT Proprietary Offender Data,UT Sex Offender,VA Circuit,VA General District,VA Fairfax,VA Proprietary Offender Data,VA Prince William,VA Fairfax,VA DOC Paroled,VA Sex Offender,VI Proprietary Offender Data,VT Proprietary Offender Data,VT DOC,VT Sex Offender,WA DOC,WA Proprietary Offender Data,WA Courts of Ltd. Jurisdiction,WA AOC SCOMIS,WA Sex Offender,Wisconsin AOC,WI DOC,WI AOC,WI Proprietary Offender Data,WI Sex Offender,WV Proprietary Offender Data,WV Sex Offender,WY Proprietary Offender Data,WY Sex Offender

Background Check Notification

 

Info Cubic. LLC. A Nationwide Employment and Tenant Screening Company 9250 E Costilla Ave. Suite 230 Greenwood Village, CO 80112 Toll Free: 1-877-360-INFO (4636) FAX: 303-220-0171 

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Notice of Background Report John Smith 1234 Main Street Oxnard, CA 93035 Dear Applicant, Enclosed is a consumer report that was requested in connection with your application for employment with our company. In accordance with the Federal Fair Credit Reporting Act, we have also enclosed a copy of your rights under the Act. You have the right to dispute the accuracy or completeness of information contained in the report(s) by contacting Info Cubic, or if the report is a credit report, contacting the credit bureau that furnished the report. Sincerely, Human Resources Department  Sample Report Company 

Enclosures: Copy of Consumer Report FCRA Notice of Rights FCRA Contact Sheet Reporting Agency Contact Information Info Cubic 9250 E Costilla Ave. Suite 230 Greenwood Village, CO 80112 1-877-360-4636   

Para informacion en espanol, visite www.ftc.gov/credit o escribe a la FTC Consumer Response Center,  Room 130‐A 600 Pennsylvania Ave. N.W., Washington, D.C. 20580       A Summary of Your Rights Under the Fair Credit Reporting Act      

 

Info Cubic. LLC. A Nationwide Employment and Tenant Screening Company 9250 E Costilla Ave. Suite 230 Greenwood Village, CO 80112 Toll Free: 1-877-360-INFO (4636) FAX: 303-220-0171 

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The federal Fair Credit Reporting Act (FCRA) promotes the accuracy, fairness, and privacy of information in  the files of consumer reporting agencies. There are many types of consumer reporting agencies, including  credit bureaus and specialty agencies (such as agencies that sell information about check writing histories,  medical records, and rental history records). Here is a summary of your major rights under the FCRA. For  more information, including information about additional rights, go to www.ftc.gov/credit or write to:  Consumer Response Center, Room 130‐A, Federal Trade Commission, 600 Pennsylvania Ave. N.W.,  Washington, D.C. 20580.   •

You must be told if information in your file has been used against you. Anyone who uses a credit  report or another type of consumer report to deny your application for credit, insurance, or  employment ‐ or to take another adverse action against you ‐ must tell you, and must give you the  name, address, and phone number of the agency that provided the information.  



You have the right to know what is in your file. You may request and obtain all the information  about you in the files of a consumer reporting agency (your "file disclosure"). You will be required  to provide proper identification, which may include your Social Security number. In many cases,  the disclosure will be free. You are entitled to a free file disclosure if:   o a person has taken adverse action against you because of information in your credit  report;   o you are the victim of identity theft and place a fraud alert in your file;   o your file contains inaccurate information as a result of fraud;   o you are on public assistance;   o you are unemployed but expect to apply for employment within 60 days.   In addition, by September 2005 all consumers will be entitled to one free disclosure every 12  months upon request from each nationwide credit bureau and from nationwide specialty  consumer reporting agencies. See www.ftc.gov/credit for additional information.  

 



You have the right to ask for a credit score. Credit scores are numerical summaries of your credit‐ worthiness based on information from credit bureaus. You may request a credit score from  consumer reporting agencies that create scores or distribute scores used in residential real  property loans, but you will have to pay for it. In some mortgage transactions, you will receive  credit score information for free from the mortgage lender.  



You have the right to dispute incomplete or inaccurate information. If you identify information in  your file that is incomplete or inaccurate, and report it to the consumer reporting agency, the  agency must investigate unless your dispute is frivolous. See www.ftc.gov/credit for an  explanation of dispute procedures.  



Consumer reporting agencies must correct or delete inaccurate, incomplete, or unverifiable  information. Inaccurate, incomplete or unverifiable information must be removed or corrected,  usually within 30 days. However, a consumer reporting agency may continue to report  information it has verified as accurate.  



Consumer reporting agencies may not report outdated negative information. In most cases, a  consumer reporting agency may not report negative information that is more than seven years 

Info Cubic. LLC. A Nationwide Employment and Tenant Screening Company 9250 E Costilla Ave. Suite 230 Greenwood Village, CO 80112 Toll Free: 1-877-360-INFO (4636) FAX: 303-220-0171 

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old, or bankruptcies that are more than 10 years old.   •

Access to your file is limited. A consumer reporting agency may provide information about you  only to people with a valid need ‐ usually to consider an application with a creditor, insurer,  employer, landlord, or other business. The FCRA specifies those with a valid need for access.  



You must give your consent for reports to be provided to employers. A consumer reporting  agency may not give out information about you to your employer, or a potential employer,  without your written consent given to the employer. Written consent generally is not required in  the trucking industry. For more information, go to www.ftc.gov/credit.  



You may limit "prescreened" offers of credit and insurance you get based on information in your  credit report. Unsolicited "prescreened" offers for credit and insurance must include a toll‐free  phone number you can call if you choose to remove your name and address from the lists these  offers are based on. You may opt‐out with the nationwide credit bureaus at 1‐888‐5‐OPTOUT (1‐ 888‐567‐8688).  



You may seek damages from violators. If a consumer reporting agency, or, in some cases, a user  of consumer reports or a furnisher of information to a consumer reporting agency violates the  FCRA, you may be able to sue in state or federal court.  



Identity theft victims and active duty military personnel have additional rights. For more  information, visit www.ftc.gov/credit.  

  

States may enforce the FCRA, and many states have their own consumer reporting laws. In some cases,  you may have more rights under state law. For more information, contact your state or local consumer  protection agency or your state Attorney General. Federal enforcers are:   TYPE OF BUSINESS:  

 

CONTACT:  

Info Cubic. LLC. A Nationwide Employment and Tenant Screening Company 9250 E Costilla Ave. Suite 230 Greenwood Village, CO 80112 Toll Free: 1-877-360-INFO (4636) FAX: 303-220-0171 

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Consumer reporting agencies, creditors and others not  listed below  

Federal Trade Commission: Consumer  Response Center ‐ FCRA Washington, DC  20580 1‐877‐382‐4357  

National banks, federal branches/agencies of foreign  banks (word "National" or initials "N.A." appear in or  after bank's name)  

Office of the Comptroller of the Currency  Compliance Management, Mail Stop 6‐6  Washington, DC 20219 800‐613‐6743  

Federal Reserve System member banks (except national  banks, and federal branches/agencies of foreign banks) 

Federal Reserve Board  Division of Consumer & Community Affairs  Washington, DC 20551 202‐452‐3693  

Savings associations and federally chartered savings  banks (word "Federal" or initials "F.S.B." appear in  federal institution's name)  

Office of Thrift Supervision  Consumer Complaints  Washington, DC 20552 800‐842‐6929  

Federal credit unions (words "Federal Credit Union  appear in institution's name)  

National Credit Union Administration  1775 Duke Street  Alexandria, VA 22314 703‐519‐4600 

State‐chartered banks that are not members of the  Federal Reserve System  

Federal Deposit Insurance Corporation  Consumer Response Center, 2345 Grand  Avenue, Suite 100  Kansas City, Missouri 64108‐2638 1‐877‐275‐ 3342  

Air, surface, or rail common carriers regulated by former  Civil Aeronautics Board or Interstate Commerce  Commission  

Department of Transportation, Office of  Financial Management  Washington, DC 20590 202‐366‐1306  

Activities subject to the Packers and Stockyards Act,  1921  

Department of Agriculture Office of Deputy  Administrator ‐ GIPSA Washington, DC 20250  202‐720‐7051  

New York State Correction Law   Article 23‐A, Section 753   Licensure and Employment of Persons Previously   Convicted of One or More Criminal Offenses  

 

Info Cubic. LLC. A Nationwide Employment and Tenant Screening Company 9250 E Costilla Ave. Suite 230 Greenwood Village, CO 80112 Toll Free: 1-877-360-INFO (4636) FAX: 303-220-0171 

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§ 753. Factors to be considered concerning a previous criminal conviction; presumption.  1. In making a determination pursuant to section seven hundred fifty‐two of this chapter, the public  agency or private employer shall consider the following factors:   (a) The public policy of this state, as expressed in this act, to encourage the licensure and employment of  persons previously convicted of one or more criminal offenses.   (b) The specific duties and responsibilities necessarily related to the license or employment sought.   (c) The bearing, if any, the criminal offense or offenses for which the person was previously convicted will  have on his fitness or ability to perform one or more such duties or responsibilities.   (d) The time which has elapsed since the occurrence of the criminal offense or offenses.   (e) The age of the person at the time of occurrence of the criminal offense or offenses.   (f) The seriousness of the offense or offenses.   (g) Any information produced by the person, or produced on his behalf, in regard to his rehabilitation and  good conduct.   (h) The legitimate interest of the public agency or private employer in protecting property, and the safety  and welfare of specific individuals or the general public.       2. In making a determination pursuant to section seven hundred fifty‐two of this chapter, the public  agency or private employer shall also give consideration to a certificate of relief from disabilities or a  certificate of good conduct issued to the applicant, which certificate shall create a presumption of  rehabilitation in regard to the offense or offenses specified therein.      DISCLAIMER The information contained in this report has been collected pursuant to a request from client and from sources deemed reliable. Client is cautioned that this material is privileged information. While every effort has been made to verify the accuracy and validity of this information, Info Cubic does not guarantee the accuracy or completeness of this report and cannot be held responsible for any actions which client may take, or cause others to take, a result of its use.

 

 

Info Cubic. LLC. A Nationwide Employment and Tenant Screening Company 9250 E Costilla Ave. Suite 230 Greenwood Village, CO 80112 Toll Free: 1-877-360-INFO (4636) FAX: 303-220-0171 

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taking ems into tomorrow By Mike Taigman

Are you ready for the next big thing in EMS?

The answer to the question of what’s next for EMS systems involves a combination of chronic disease management, public-health partnerships, prevention and deep listening to the needs of our customers.”

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sk any group of paramedics who the frequent-flyer diabetics are in their service areas, and they’ll tell you where the good veins are on these patients. More often than not, we’ll wake someone up with a little IV sugar, and they’ll say they don’t want to go to the hospital. We’ll tell them to eat something more substantial than Nacho Cheese Doritos and call us back if they have any more problems. Get a signed refusal, and we’re back in service. Most first responders can give you detailed directions to the homes of people who regularly call because they’ve fallen and can’t get up. We’ll show up, make sure they’re not hurt and help them to the bathroom, then back to

bed. Chances are we won’t even fill out a patient care report; we’ll just tell dispatch we’re back in service after a public assist or a “reset the occupant.” These routine calls don’t get much airplay back at the station. They don’t generate an automatic QA review. Yet these kinds of calls hold the potential to allow EMS systems to save more lives and prevent more suffering and disability than we could by having an AED on every street corner. What’s going to be the next big thing in EMS? Will it be a new treatment device—perhaps a self-installing CPR vest that delivers sternal intraosseous medications, while filling the lungs with frozen slurry, as it wirelessly notifies the www.emsresponder.com ■ EMS ■ MAY 2006

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operating room resuscitation team on their video iPods? Will it be a new medication—something that stops internal bleeding in trauma patients while improving their IQ? Will it be a new diagnostic device—something that provides a whole-body CAT scan, fits in the front pocket of your trauma bag and makes skinny decaf soy lattes? Management guru Peter F. Drucker once said, “The best way to predict the future is to create it.” While over the last few decades we’ve steadily improved our ability to reanimate people whose hearts have stopped beating, and our systems have advanced so that fewer people die from trauma, it’s been a long time since we’ve made significant improvements that help lots of people. The rest of healthcare, however, is making dramatic improvements. In December 2004, the Institute for Healthcare Improvement (IHI) launched its 100,000 Lives campaign. The motivation for this proj-

• Make heart-attack care absolutely reliable; • Stop medication errors. As he spoke, a couple of simple improvements that EMS systems could implement popped into my mind. We could improve our hand-washing systems and processes, which in hospitals dramatically decreases IV-related infections. We could help local hospitals develop and train their rapid-response teams, which function something like inhouse paramedic teams. We can double-check our cardiac chest pain protocols to make sure patients get aspirin early. We can make sure all of our systems are working closely with their local cardiologists to ensure that MI patients are identified early and transported to places where they can get either stents or clot-busting drugs quickly. But while these actions would contribute to the overall improvement of healthcare, they don’t seem like enough.

Anatole France, who won the Nobel Prize for literature, said, “To accomplish great things, we must not only act, but also dream; not only plan, but also believe.” ect came from the 1999 Institute of Medicine report that concluded that nearly 100,000 people die in hospitals each year—not as a result of their diseases or injuries, but because of injuries and infections caused by their medical care. As I sat in an audience of over 10,000 physicians, hospital administrators and medical-school professors listening to IHI president Don Berwick, MD, lay out their plans, I wondered how EMS systems could contribute. Berwick described six areas in which hospitals could dramatically decrease deaths caused by treatment: • Prevent respirator pneumonia; • Prevent IV-catheter infections; • Stop surgical-site infections; • Rapid-response teams in hospitals;

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The time has come for us to fundamentally change the role of EMS systems in our communities. We have resources, competencies and relationships that no other part of the healthcare system has. We can identify community disease patterns faster than most public-health departments. We understand the geographic patterns of injury and disease in our communities. People trust us in their homes, neighborhoods and workplaces. They trust us with some of the most vulnerable aspects of their lives. With our patient record systems, we know who the sickest people are in our areas. When we run calls to the homes of people with chronic diseases, we can tell who is taking good care of themselves and who isn’t.

The reality is that we are pretty darn good at responding to and taking care of sudden injuries and illnesses in our communities. Some EMS systems have embraced prevention measures like child car seat inspections, pool-safety education to reduce drownings, and prom night DUI programs. The answer to the question of what’s next for EMS systems involves a combination of chronic disease management, public-health partnerships, prevention and deep listening to the needs of our customers. Here are some possible objectives for the radical improvement—and even transformation—of what EMS systems offer their communities: • Facilitate the self-care of brittle diabetics. • Help families decrease the number of asthma attacks that send their children to emergency departments. • Help decrease the chance that the elderly will fall in their homes. • Help chronic CHF patients take better care of themselves so that they avoid the exacerbations that cause them to be admitted to hospitals. • Deliver all patients to hospitals pain-free. Some people will read this list and say, “That’s not EMS’s responsibility.” Others will think, “That doesn’t sound as cool as dropping tubes, venting chests and saving lives.” Still others will say, “I’m not willing to take on that liability.” Over the next several months, EMS Magazine will run a series of articles that will show you the monumental difference we could be making in the lives of hundreds of thousands of people. We will share specific actions that can be put into place in your EMS systems. This may be the beginning of a revolution in our world. The bus is leaving, and you won’t want to be left behind. Mike Taigman is a lifelong student who has been involved with EMS for over 30 years. He works with EMS systems worldwide, helping them take better care of their employees and the people they serve. For more, see www. miketaigman.com.

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Photos by Dan Limmer

By Ann Williams, PhD, MSN, Anne Whittington, MBA, MSN, RN, CDE, & Mike Taigman

How you can help your community live with diabetes

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ome people call it “paramagic.” He is unconscious, unresponsive, pale, cool, drenched in sweat, snoring respirations, with his spouse hovering over him, wringing her hands and warning us he’s diabetic. While murmuring words of comfort to the family, we gracefully slip a catheter into an elusive vein. We gently squeeze the syringe full of syrupy sugar water, watching carefully for infiltration. As the plunger on the amp of D50 reaches the halfway point, his breathing starts to normalize, and his pasty cheeks fill with color. Gradually he wakes—a little confused at first. Soon he says something like, “Guess I forgot to eat lunch today.” This process is one of the coolest things we get to do in EMS, and we get to do it a lot. Waking up someone who looks near death from hypoglycemia is paramagic at its finest. But it’s rare that an EMS provider looks much beyond the emergency to see the big picture of diabetes for their patient. According to the Centers for Disease Control and Prevention, there are 14.6 million people in America who have been diagnosed with diabetes. It’s estimated that 6.2 million have diabetes that has yet to be diagnosed, and more than 41 million have pre-diabetes. That means nearly one in five Americans is suffering from, or is at risk for suffering from, the complications of diabetes.

The list of complications from this disease is long and daunting. The short-term complications, hypo- and hyperglycemia, are the ones with which EMS providers are most familiar. It’s also important that we become aware of the devastating long-term complications. Diabetes is the leading cause of kidney failure, accounting for 44% of new cases in 2002. Diabetic retinopathy is the leading cause of new blindness in adults 20–74. People with diabetes account for more than 60% of lower-limb amputations (over 82,000 in 2002), and 73% of people with diabetes have high blood pressure, which leads to myocardial infarction and stroke. In one state surveyed, 26% of people with diabetes reported having had a myocardial infarction or stroke, compared with 6% of the www.emsresponder.com ■ EMS ■ JUNE 2006

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Significant hyperglycemia is the cause of many complications.

nondiabetic population. Diabetes is not an equal-opportunity disease. According to the CDC, Native Americans and African Americans are more than twice as likely to have diabetes as whites. The rate among Latinos and Asian Americans/Pacific Islanders is also

higher than among whites. Diabetes is more common in people without high school educations, with household incomes less than $15,000 a year, and without telephone service. More than 20% of people over 65 have it. Mortality rates associated with diabetes are also rising. Rates from 1999–2001 were 61% higher than from 1989–91. “Diabetes has reached epidemic proportions in the U.S.,” says Dr. Michael Alderman, professor of epidemiology and population health at Yeshiva University’s Albert Einstein College of Medicine. And according to Paul Zimmet, director of the International Diabetes Institute, it’s estimated that more than 330 million people worldwide will be affected with diabetes within the next 20 years. The epidemic is happening faster in Asia than in any other region. One researcher predicts that if current trends continue, by 2020 all

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the insulin presently manufactured in the world will not be enough for China alone. Insurance companies are not helping reverse these trends. Diabetic self-management education programs receive meager reimbursement from insurance companies, while treatment for severe complications is paid for. A January 2006 New York Times article described how over the last seven years, three of the four hospital-based diabetes programs in New York City closed their doors due to lack of funding, while the number of people with type II diabetes doubled. The article said, “Insurers, for example, will often refuse to pay $150 for a diabetic to see a podiatrist, who can help prevent foot ailments associated with the disease. Nearly all of them, though, cover amputations, which typically cost more than $30,000.” The good news is that many of the

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Insulin Pumps One of the most exciting innovations in diabetes care is the insulin pump. Many people with diabetes now prefer these pumps to syringe injections. Insulin pumps are computerized devices, about the size of a pager or cell phone, that people wear on their belts or carry in their pockets or special holders. They deliver a steady, measured dose of insulin (the basal dose) through a flexible plastic catheter. The pump releases very small doses continuously, which mimics the body’s normal release. When people using a pump eat, they press a button to deliver a bolus of insulin to help them metabolize the carbohydrates in their meal. These devices allow people with diabetes to adapt their insulin to their lifestyle, and give them much greater control over their blood sugar. More and more of the patients cared for by EMS will have insulin pumps. There are so many brands on the market that it’s not reasonable for EMS providers to know how to trouble-shoot all of them. Here are some rules of thumb for treating patients with insulin pumps. • If your patient is hypoglycemic and you’re able to start an IV and give D50, leave the pump in place. • If your patient is hypoglycemic and you’re not able to start an IV, disconnect the pump so that the patient isn’t continuing to get insulin when their blood sugar is low and you can’t give D50. Just pull the catheter out of the skin—it’s easy to reinsert later. Note: These pumps are very expensive ($5,000–$6,000 or more), so tape the disconnected pump to the patient’s arm. Using a little gauze wrap before your tape will prevent allergic reactions to the adhesive. Patients can go without their pump for 2–3 hours before they begin to develop diabetic ketoacidosis. • If your patient is in diabetic ketoacidosis, ask them to check their pump to make sure it’s working and has insulin.

most severe complications of diabetes can be prevented or dramatically decreased. Diabetics who obtain and maintain control over their blood sugar and blood pressure can live

long and healthy lives. People with diabetes can learn to manage their disease, and EMS providers can support them in their efforts.

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TYPES AND HOW TO CONTROL THEM There are two primary types of diabetes, type I and type II. Type I, formerly called juvenile-onset diabe-

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tes because it tends to strike persons before the age of 20, affects about 5%–10% of people with diabetes. With this type of diabetes, the pancreas makes no or almost no insulin. Type II diabetes was previously called adult-onset diabetes because in the past it was usually discovered after age 40. However, with Americans’ sedentary lifestyles and increasing levels of obesity, this disease is now being found more in adolescents—and sometimes even in children under 10. Type II diabetes constitutes about 90%–95% of all cases. With this type of diabetes, either the pancreas produces a reduced amount of insulin, cells do not respond to the insulin, or both. For people with diabetes, an important key to preventing complications and staying out of ambulances and EDs is controlling blood glucose. To do this, people need to learn to balance medication, diet

and physical activity every day. The mechanism that lets someone know how much control they have over their disease is blood sugar measurement. People should check their own blood sugar as often as they need the information. For people who have fluctuating blood sugar, this is often four or more times a day. For those with stable blood sugar, once a day may be sufficient. It’s important for EMS providers to remember that illnesses (like the flu) or trauma frequently cause blood sugar problems for people with diabetes. At least twice each year, people with diabetes should have an A1C blood test performed. This test assesses the average amount of sugar in the blood over a 2–3-month period. It’s a good overall indicator of how controlled a person’s blood sugar is over time. The closer a person with diabetes can keep their A1C to 6% or lower, the better their

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diabetes is in control. A 1% change in A1C results reflects a change of about 30 mg/dL in average blood glucose. For instance, an A1C of 6% corresponds to an average glucose of 135 mg/dL, while an A1C of 9% corresponds to an average glucose of 240 mg/dL. Every percentage point drop closer to 6% in A1C blood test results reduces the risk of microvascular complications to the eyes, kidneys and nerves by 40%. The feedback from daily blood sugar tests and regular A1C blood tests allows a person with diabetes to work with his or her healthcare professionals to adjust medications, diet and exercise to fine-tune their self-management program. We need to understand that helping someone with diabetes obtain and maintain control over his or her blood sugar and blood pressure is as lifesaving as shocking someone’s fibrillating heart. For people with type

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I diabetes, keeping blood glucose levels as close to normal as possible reduces damage to the kidneys by 35%–56% and the eyes by 76%. Blood pressure control reduces risk of cardiovascular and microvascular disease by 33% and decline in kidney function by 30%–70%. As a general rule, for every 10 mm Hg reduction in systolic blood pressure, the risk for any complication related to diabetes is reduced by 12%. Add a comprehensive foot care program, and you can reduce amputation rates by 45%–85%. For most people with diabetes, the distinct activities involved in gaining and maintaining control over their blood sugar are not difficult. The hard part seems to be keeping the balance and consistent good practices alive every day. Researchers conducted a phone survey of people with diabetes in Oklahoma and found that only 57% checked their blood sugar each day, only 52% had regular A1C blood tests, only 65% had a professional foot exam during the last year and only 66% had a dilated eye exam. Just 56% had ever taken a class on how to manage their disease. A recent report published in JAMA found that only 37% of adults with diabetes achieved an A1C of less than 7%, only 36% had a blood pressure less than 130/80, and just 48% had cholesterol less than 200 mg/dL. Only 7.3% achieved all three treatment goals. While we don’t know for sure, chances are good that the people who don’t practice good self-management are more likely to receive care from their local EMS systems than those who do.

Researchers conducted a phone survey of people with diabetes in Oklahoma and found that only 57% checked their blood sugar each day.

help and support managing their disease. It’s well within the capabilities of EMTs, paramedics and EMS systems to make dramatic improvements in the lives of people with diabetes. There are many things EMS providers and systems can do to help people with diabetes live longer,

healthier lives. Some can be done right away, some require system and protocol changes, and some should be explored through proper research studies. It’s important, as we venture into new territory, to remember the basics: Each patient and their presenting problem should be treated

WHAT DOES IT MEAN? So what does all this mean for EMS providers and their systems? We already see lots of people with diabetes, and we’re going to see more if rates continue to rise as predicted. If someone with diabetes needs EMS services, they need more than an amp of D50 and a lecture about eating when they take their medication. They also need For More Information Circle 61 on Reader Service Card www.emsresponder.com ■ EMS ■ JUNE 2006

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with current protocols first. Here are some possibilities to consider: 1) Learn more about modern diabetes management. Take a class in diabetes education. Diabetes treatment changes rapidly. If you learned

• Team Management of Diabetes, offered by the International Diabetes Center, www.parknicollet.com/CME/ diabetes/tmd.cfm. • Diabetes Education Update at Wichita State University, http://webs.

Helping someone with diabetes obtain and maintain control over his or her blood sugar and blood pressure is as lifesaving as shocking someone’s fibrillating heart. about diabetes treatment more than three years ago, your knowledge is out of date. Examples: • Core Concepts, offered by the American Association of Diabetes Educators, www.diabeteseducator. org/ContinuingEducationCE/concept.shtml.

wichita.edu/?u=conted&p=/diabetes_education_update/. Many other programs teach diabetes education and treatment to professionals. 2) Take and document a thorough history on each patient. Diabetes educators encourage EMS

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providers to learn about modern diabetes self-management techniques before adding a history this detailed to their practice. Otherwise it will be difficult for EMS providers to accurately answer the questions that will come from patients as this information is gathered. • Assess their diabetes self-management knowledge and practices. • Is there a blood glucose meter in their house? If so, has it been used and calibrated? • How often do they check their blood sugar, and do they keep a record of their results? If they don’t check their sugar daily, why not? • What type of exercise do they get, and how often? • Do they follow a meal plan or diet? • Assess their support system: Do they live alone? Do they have someone who provides them with education about managing their disease?

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Figure 1: EMS Referral to Diabetes Education

Do their family members know how to use their blood glucose meter? Record names and contact information of the people in their support system. • How many times in the last month have they had a low blood sugar reaction, weakness, sweating, anxiety, trembling or a headache? • How many times in the last year have they had such severe low blood sugar that they passed out from it or needed help from someone? • How many days in the last month have they had high blood sugar with symptoms like thirst, dry mouth, sugar in the urine, low appetite, nausea or fatigue? • Do they have a kit for the emergency administration of glucagon? Have their friends and family been trained in its use? 3) Perform a thorough diabetic foot exam. Inspect the foot between the toes and from toe to heel. Examine the skin for injury, calluses, blisters, fissures, ulcers or any unusual condition. • Look for thin, fragile, shiny and hairless skin—all signs of decreased vascular supply. • Feel the feet for excessive warmth and dryness. • Remove any nail polish. Inspect nails for thickening, ingrown corners, length and fungal infection. • Inspect socks or hose for blood or other discharge. • Examine footwear for torn linings, foreign objects, breathable materials, abnormal wear patterns and proper fit. • Check the dorsal pedal and posterior tibial pulses. • Ask if they have pain in their feet while at rest. • Ask if they have numbness in their feet or legs. If you find anything that suggests a patient may have or be heading toward problems with their feet, encourage them to allow you to transport them to the hospital. Include your findings and concerns in your report to the emergency department staff. If the patient refuses transport, advise them and their family members that they should see their healthcare provider, physician or a podiatrist ASAP for a complete foot exam. 4) Set up a system to “adopt” people with diabetes who give you permission to facilitate their self-management. Communicate with their primary care physician and diabetes educator about your willingness to help. Call each day and ask what their blood sugar is, what they’re planning to eat and what physical activity they’re planning to engage in. Record their results on a spreadsheet or in a database. Monitor their progress and notify them and their physician of any problems. 5) Find out what diabetes-related treatment, support and education organizations exist in your service area. You can log onto the American Association of Diabetes Educators website (www.aadenet.org), click on the Diabetes Education tab and find certified educators in your area, or log onto the American Diabetes Association

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Patient Name: ___________________________________________________________________ Phone (home) _______________ (work)__________________(cell) _______________________ (If we can’t reach them at above numbers) Other Contact/relationship _______________________________________________________ Other Contact Phone (___) ________________________________________________________ (not someone they live with) Address: ________________________________________________________________________ Insurance Provider: ____________________________Acct Number ______________________ Physician: _______________________________________________________________________ Contact Person: ___________________________________Phone: _______________________ This patient was seen on ____________________________(date) for ___________ Severe hypoglycemia ___________ Severe hyperglycemia ___________ Other (please specify)______________________________________________ The blood glucose value measured by an EMS was _______________________mg/dl. ________________ The patient uses insulin ________________ The patient does not use insulin The patient was:

___ treated and refused to go to a hospital ___ treated and transported to: __________________________________

Complications and co-morbidities including __ Hypertension __ Dyslipidemia __ Stroke __ Neuropathy __ Nephropathy __ Peripheral Vascular Disease __ Renal Disease __ Retinopathy __ Pregnancy __ Coronary Heart Disease __ Non-healing wound __ Obesity __Mental/affective disorder __ Other _____________________________________________ Other information about patient: _________________________________________________

Patient referred by ______________________________________________________________ Name of EMS Provider Agency: ________________________________________________________________________ Permission to provide medical information to physician and diabetes educator: I ___________________________________ give permission for the EMS providers to provide/discuss and/or receive medical information including medical records concerning my diabetes and other health issues with my physician hospital staff and diabetes educators. This release is required to obtain medical information according to the privacy rule detailed in HIPPA (The Health Insurance Portability and Accountability Act of 1996). Patient Signature _____________________________________ Date ______________________

Education Recognition Program website (www.diabetes. org/education/edustate2.asp) and search your state for ADA-recognized diabetes education programs. Invite representatives from these organizations to lunch and discuss ways your EMS system can facilitate the work already going on in your community. See if it’s possible to have your EMS system refer patients directly to educators for diabetes self-management education. 6) Create diabetes assessment and referral forms that your crews can fill out and fax, e-mail, hand-deliver or leave with the patient to deliver to the patient’s physicians and diabetes educators (with a signed HIPAA release, of course). See Figure 1. 7) Ask your local diabetes education program to provide your crews with diabetes self-management materials they can give to patients and their friends and family. Determine whether people are able to read the material you provide. Recent research indicates that illiteracy is more common in this country than most people believe, among both people whose first language is English and others. People who never learned to read don’t usually announce that to the people taking care of them. Also, many people with diabetes have trouble seeing, so their educational information may need to be in an audio format. continued on page 99 212

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WHOSE JOB IS IT? We are aware that some of you reading this article have little voices in the backs of your minds saying things like, “This isn’t the responsibility of EMS,” “Don’t you know we deal with emergencies? This is chronic disease management,” “Checking feet doesn’t sound nearly as cool as venting chests—this isn’t what I signed up for,” and “Who’s going to pay for this?” These voices are stuck in the past. They have a very small view of what we can and should do for our communities. A few of you are thinking, With just a little bit of extra work, a few additions to our training and protocols and a little shift in our selfimage, we could make an important difference in the lives of the people we treat. With a bit of effort, we could dramatically change our relationships with our communities. You are right. It’s time to have your EMS system make the shift from a response model to a public-health model. A public-health model is one that accepts stewardship of facilitat-

ing disease management for people with diabetes who have contact with the EMS system. We can become the best partners our departments of public health could ever wish for. And most important, we could decrease suffering and save more lives than we ever imagined. Ann Williams, PhD, MSN, is dedicated to empowering people to live long and healthy lives. She is also an RN and a certified diabetes educator (CDE), and has had diabetes herself since 1991. She has used insulin since 1992, and has never needed to call EMS to provide care. Anne Whittington, MBA, MSN, RN, CDE, is the Diabetes Program Manager of the Health Promotion Department for the Naval Medical Center in San Diego. In addition to overseeing diabetes training for the Pacific Fleet of over 250 ships, she and her seeing eye dog, Karl, created Paws for Healing, which is the first program to combine pet therapy, therapeutic outing and reintegration into society for war-injured U.S. Marines. She’s been an EMS customer just once. Mike Taigman is a lifelong student who works with EMS systems worldwide, helping them improve the services they provide. Blood tests indicate he has pre-diabetes. He’s been an EMS customer, but it had nothing to do with diabetes. Contact him via www.miketaigman.com.

hot shots: new products, services and equipment HEAVY-DUTY GO STRETCHER GO Manufacturing Innovations announces the introduction of the Heavy Duty GO Stretcher, designed to meet the needs associated with the transport and handling of large and obese patients. The stretcher can be used as a disposable emergency stretcher for everyday transport of large and obese patients, as a disposable emergency stretcher for MCIs, as a disposable patient transfer system to move the patient from the backboard to the hospital gurney and as a disposable gurney sheet. Call 314/664-0164. Circle 79 on Reader Service Card

cont. from page 43

The department aims to collect three years’ worth of data before formally determining if more people are being saved by this method, but similar projects elsewhere have them optimistic. “One of the reasons we decided to do it was it looked like there was very little downside,” Valenzuela says. “It seemed unlikely we could harm anybody by doing it. It seems to go a little more smoothly than it did before. Whether we’re actually saving more people, we’ll know pretty soon.” As exciting as the coming years look for EMS, Valenzuela’s biggest concerns for his service run toward the mundane—things like modernizing training and keeping rising call volumes from overwhelming his system. “One thing we’re looking at,” he says, “is whether we can create an intermediate tier of response, geared toward minor problems, that doesn’t necessarily result in only two choices (refusal or transport). We’re looking at ways we can treat and release more people, and for ways that people who call 9-1-1 and don’t really have a medical problem—because it’s the only way they know to get help—can be hooked into community resources and get their problems addressed. “Fortunately, in Arizona they’ve set up the regulatory framework to allow a lot more treat-and-release. The hard part is figuring out how to do it safely.”

ALL-TERRAIN RES-Q TRAILER Empire Welding & Fabricating Co. Inc. introduces its All-Terrain Res-Q trailer. With the growing need for deep-woods rescues, the Res-Q has advantages over traditional ways to rescue accident victims with less manpower. The trailer features a combination shock and spring suspension, high-flotation tires, dual ratchet straps, IV pole and a multi-combination tongue to attach to towing vehicle. Call 888/698-3867, or visit www.allterrainresq.com. Circle 80 on Reader Service Card

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asthma management By Laurie Romig, MD, FACEP, & Mike Taigman

Asthma affects millions of Americans—here’s how to reduce its impact in your community Photo by Dan Limmer

“While jogging, I get out of breath, just like anyone doing strenuous exercise. Each breath takes in less and less air as my lungs rebel against the exertion and begin to constrict. I stop running, and my breathing doesn’t improve—it’s shallow and strained. With each breath, less and less air is getting through. My head becomes light, and it pounds inside like someone’s hammering. The blood feels like it’s pooling in my head, trying to keep me awake. My diaphragm and rib muscles are no longer strong enough to draw air in—I have to bend halfway over and brace my hands on my knees, struggling to inhale. It feels like someone has covered my mouth and nose with a soaking wet washcloth, or that I’m trying to suck all of my air through a coffee straw. I begin to feel faint. I start to panic when I realize I can’t exhale. I’m face to face with death.” —Asthma sufferer Chad Council, describing an attack 86

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hen someone calls EMS for an acute asthma attack, chances are good that the professionals who arrive can help them feel better fast. Along with people who are hypoglycemic from diabetes, asthmatics are among those patients for whom our treatment really makes a clear, quick difference. It’s amazing how quickly people who feel like they’re going to die can have their breath restored and their blood oxygenated. In most communities, breathing problems are among the top reasons people dial 9-1-1. Asthma makes up a significant percentage of these calls. If you talk with EMS providers, most of them have regular asthma “customers.” In most EMS systems these patients, after treatment, are transported to an

and tighten. Often, especially in the early stages of an attack, patients notice an inability to breathe out fully against the swelling in the airways. Air begins to “stack up” in the chest, and patients have to work harder to move air in and out. These exacerbations are triggered by a number of irritants and stressors. The cause of asthma is still unknown. What we do know is that atopy, the genetic tendency to develop allergic diseases, is the most important predictor of whether a person will develop asthma. If one parent has asthma, chances are 1 in 3 that their child will have asthma. If both parents do, the chances are 7 in 10. While asthma affects people of all ages, races and ethnic groups, it is not an equal-opportunity disease. Low-income groups and minority populations have higher rates

Each day in America: • 40,000 people miss school or work due to asthma • 30,000 people have asthma attacks • 5,000 people are seen in emergency departments due to asthma • 1,000 people (more than half of whom are children) are admitted to hospitals due to asthma • 14 people die from asthma emergency department. That’s wonderful but inadequate. We have the capability to do much more for these folks than just opening up their tight lungs.

WHAT IS ASTHMA? Asthma is a Greek word meaning to exhale with open mouth, to pant. It appeared for the first time in the Iliad, and there meant a short-drawn breath. Asthma is a chronic inflammatory disease characterized by recurrent episodes of breathlessness, wheezing, coughing and chest tightness. An asthma attack causes the muscles surrounding the airways in the lungs to swell, become inflamed

of fatalities, hospital admissions and emergency department visits. Children from low-income families are five times more likely to be hospitalized for asthma than those who are financially better off. While asthma rates for African-American children are only slightly higher than those of white Americans, black children die from asthma at a rate four times that of whites. Puerto Ricans have significantly higher rates of asthma than all other groups.

CONTROLLING ASTHMA Studies show that asthma attacks can be cut dramatically—by up to 73%—with proper use of medica-

Using a Metered-Dose Inhaler Correctly 1. Remove the cap and hold the inhaler upright. 2. Shake the inhaler and install the spacer, if you’re using one. 3. Sit up straight and tilt your head back slightly. 4. Breathe out. 5. Open your mouth and hold the inhaler an inch or two away from it. 6. As you start to breathe in, slowly press down on the inhaler to release the medicine as you breathe in for 3–5 seconds. (If you’re using a spacer, press down on the inhaler and then slowly begin to breathe in after waiting five seconds.) 7. Hold your breath for a count of 10 to allow the medicine to go deep into your lungs. 8. If you need another puff, wait one minute before the next one. This will allow your lungs to open so the next puff is more effective. Tips: Dry-powder capsule inhalers are used differently. To use a dry-powder inhaler, close your mouth tightly around the mouthpiece and breathe in quickly. Keep the mouthpieces of all inhalers clean. They can become a breeding ground for bacteria and viruses that can trigger the very asthma attacks they’re intended to prevent. It’s difficult to tell when an inhaler is running out of medication, so it’s best to start with two and replace one each time it runs out. Pharmaceutical companies have warned of a possible inhaler shortage in coming months. If people aren’t able to fill their prescriptions, this could cause an increase in EMS calls for asthma.

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Dust Mites

EMS providers can inadvertently trigger or worsen a patient’s asthma attack if their skin, hair or clothes smell of cigarettes. tions, avoiding exposure to things that trigger attacks, and routine selfmonitoring. But that doesn’t mean all asthma sufferers take their disease as seriously as they should. One study of inner-city adolescents found that 41% did not know the names of their asthma medications, and only 38% carried their inhalers with them. Yet 39% reported having had asthma attacks that were so bad, they were afraid they were going to die. One study showed that fewer than half of children living in lowincome inner-city areas were using anti-inflammatory medications such as steroid inhalers. There are several things a person can do to reduce asthma attacks. One is to regularly use a controller medication, usually inhaled corticosteroids. These are taken every day to reduce inflammation in the lungs, which prevents or reduces the symptoms of asthma. Rescue medications, conversely, are taken at the first sign of symptoms, including wheezing, coughing, chest tightness or shortness of breath. Rescue medications can also be used before exercise to prevent an attack. To be effective, controller medications must be taken regularly, and rescue medications must be with the person at all times. Both must be administered properly to work properly. Fewer than half of people with asthma use their inhalers properly. Regular monitoring of peak expiratory flow rates can give patients early warning of impending attacks. A peak flow meter for asthma is like a thermometer for a fever: It lets the

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patient know what’s going on with their lungs at a level they may not be able to feel. It also gives them feedback on the effectiveness of their treatment and an ability to monitor the severity of their disease. There are many things that can trigger an asthma attack, most of which can be controlled with minor changes in home and lifestyle.

Tobacco Smoke Tobacco smoke is one of the most common asthma triggers. Of course asthma patients should not smoke, but it is also wise for other family members, housemates and visitors to not expose such patients to their smoke. This may act as a great motivator to get these friends and loved ones to stop smoking; if not, they should at least be prohibited from smoking in the house, car or any area the patient must enter frequently. EMS providers can inadvertently trigger or worsen a patient’s asthma attack if their skin, hair or clothes smell of cigarettes. Of course people who smoke in ambulances, front or rear, are harming their patients.

Dust mites thrive in soft surroundings like pillows, mattresses, carpets and drapes. These microscopic organisms give off particles that cause allergic reactions when inhaled. They need moisture to survive, so they flourish in humidity. Hypoallergenic mattress and pillowcase covers provide a barrier between house dust mites and people with asthma. Down-filled pillows, quilts or comforters, which can contain large numbers of mites, should not be used. Experts used to suggest synthetic pillows; however, recent studies have shown that more dust mite allergens can be found in synthetic pillows than in feather pillows. Research reported at the annual meeting of the American Academy of Allergy, Asthma and Immunology (AAAAI) shows that synthetic pillows may contain more pet allergens than feather pillows. Regardless of its material, if the pillow is washable, wash it regularly. You can also fluff it occasionally in the dryer to remove dust mites, but make sure the dryer is on its hottest setting. Remove stuffed animals from the bedrooms of children with asthma. That’s easy for us to say; some parents reading this may be thinking, “Better to deal with an asthma attack than the wrath of a child who’s had Fluffy wrestled from her clutch!” So if a child with asthma wants to play or sleep with a stuffed toy, it should be washed frequently in hot water (at least 130ºF) or put in the freezer for a few hours every week (freezing kills dust mites as effectively as hot water). All bedding should also be washed weekly in hot water. Replacing drapes with blinds that can be cleaned more easily also helps. Tile or other hard

In large cities that have air pollution problems, people with asthma should remain indoors on high pollution alert days.

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Using a Peak Flow Meter

Photo by Dan Limmer

These meters measure how forcefully a person is able to blow air out of their lungs. Single readings aren’t very helpful in determining how well asthma is under control; patients should take and record morning and evening readings daily for several weeks. To take a peak flow reading: Peak flow meters allow 1. Set the pointer on the meter at zero. asthmatics to track 2. Stand in an upright position (sit if unable to stand). their condition. 3. Hold the meter level and keep your fingers away from the pointer. 4. Take a deep breath and close your lips firmly around the mouthpiece. 5. Blow as hard as you can, as if you were blowing out candles on a birthday cake. Remember, it’s the speed of the breath that’s being measured. 6. Look at the pointer and check the reading. 7. Repeat this process three times and record the highest reading in your personal asthma journal. The highest number recorded over a two-week period when the patient is feeling well, with their asthma under good control, is the personal best. Once this personal best is determined, the patient’s physician can calculate a “traffic light” system for rating the severity of the asthma: • Green Zone (80%–100% of personal best)—No asthma symptoms, no changes in routine treatment or medications. • Yellow Zone (50%–80% of personal best)—May be having an asthma episode that requires action to prevent exacerbation. Patient may be coughing, wheezing or short of breath, and rescue medication may be indicated. If measurement doesn’t return to the green zone after treatment, patient should seek healthcare. • Red Zone (below 50% of personal best)—Asthma alert; take an inhaled beta2-agonist right away. Contact 9-1-1 if the peak flow does not return to the yellow or green zone quickly. Some physicians suggest zones with narrower bands. Patients should follow their physicians’ guidelines. flooring offers advantages over carpet; frequent floor and furniture dusting helps as well. There are also many products on the market, such as air-filtration systems and cleaning products, that promise to reduce allergens from dust mites and other household asthma triggers.

Outdoor Air Pollution Pollution caused by industrial emissions and automobile exhaust can cause asthma episodes. In large cities that have air pollution problems, people with asthma should remain indoors on high pollution alert days. If vehicle travel is unavoidable, keep the windows rolled up and the air conditioner on. Keep this in mind as patients are transported in ambulances.

Pollens Many people with asthma also have seasonal allergies with sensitivities to various types of pollen. Interventions that can decrease expo-

sure to these allergens can include wearing a surgical mask while outside, planning to be outside at times of day when pollen counts are lower (during afternoons and evenings or after heavy rains), keeping house windows closed and air conditioning or heat on, drying clothes in a dryer rather than outdoors, and monitoring area pollen counts and advisories via the Internet, television or newspaper.

Cockroach Allergens Cockroaches can be found anyplace people eat food and leave crumbs behind. Decreasing exposure to cockroaches in the home can help reduce asthma attacks. These little creatures need food and water to survive. People tend to eat where they watch TV, so pay close attention to these areas. Remove sources of water and food, including pet food. Clean every 2–3 days using a vacuum equipped with a high-

efficiency particle-arresting (HEPA) filter. Wash dirty dishes immediately after use. Discardable food containers should be thrown away in an outdoor trash bin. Standing water should be removed from all rooms. Don’t forget to check the trays under self-defrosting refrigerators. Roach traps or gels can also be used to decrease the number of cockroaches in the home. Cleaning methods for removal of dust mites and animal dander also assist in removal of cockroach allergens.

Pets Furry pets, particularly cats and rodents, may trigger attacks. People aren’t allergic to their pets’ fur; it’s the dander that causes reactions, so giving a pooch a haircut will not help. Pets should not be allowed in the patient’s bedroom—they should be kept outside as much as possible and bathed weekly. Frequent vacuuming will also help; if the floor has a hard www.emsresponder.com ■ EMS ■ JULY 2006

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Decreasing exposure to cockroaches in the home can help reduce asthma attacks. surface, it should be damp-mopped weekly to pick up dander. Use pet beds or blankets that are washable and launder them weekly. Finding another home for sufferers’ pets would dramatically reduce allergens in the home, but that’s not an option most pet owners would like to exercise. If an asthmatic person insists on having a pet, certain breeds of animals, especially dogs, may be more asthma-friendly than others.

Mold Inhaling mold spores can cause an asthma attack. Mold can grow almost anywhere, outdoors and in, especially in humid areas like bathrooms, showers and basements. Controlling moisture levels by keeping humidity between 35%–50% helps decrease its ability to grow. A gauge called a hygrometer can be used to monitor humidity levels. Air conditioning and dehumidifiers help keep moisture levels under control. If, for some reason, a humidifier must be used in the home, it should be cleaned weekly with diluted bleach, and the water changed daily so that mold does not grow. Use an exhaust fan or open a window when cooking or taking a shower. Empty water pans found below self-defrosting refrigerators, in some wall-mounted air conditioners and in dehumidifiers weekly. Remove spoiled foods from refrigerators immediately and empty

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the trash frequently. Make sure the clothes dryer is vented to the outside. Dry clothes immediately after washing them. Ideally, people with asthma should not have their bedrooms on the basement level. Also, they should not have potted plants in their bedrooms, because the soil is a breeding ground for mold. There are a multitude of other things and situations that can trigger asthma attacks, including strenuous physical exercise, cold air, high humidity, thunderstorms, some foods and food additives, rhinoviruses, domestic birds, formaldehyde, fragrances, aspirin, beta-blockers, sulfites in food (dried fruit) or beverages (wine) and respiratory infections. Strong emotional states can also provoke attacks.

WHAT EMS CAN DO The primary focus for EMS, of course, is to provide appropriate treatment for acute asthma symptoms according to local protocols. This alone may keep you busy for the whole call, but more often than not, there’s also time to do a little teaching. If you’re transporting, the ambulance ride can be a perfect time for one-on-one education. If you’re leaving the patient at home, a few

ance with their treatment program. You can use these points to assess the “asthma IQ” of your patient or their caregiver. Research shows that the more people know about their disease, the better their chances of controlling it. Find out whether they monitor their symptoms with a peak flow meter. If they do, have them show you how they use it and make sure they’re doing it correctly. Ask if they have a journal of peak flow reading, symptoms and potential triggers. If they don’t, encourage them to start keeping one. Most patients lock their lips around their inhalers as if they were prom dates. Have them show you how they use theirs, and correct their mistakes. Reinforce the importance of using controller medications (corticosteroids) regularly and rescue medications (beta2-agonists) at the earliest sign of a problem. Take the opportunity whenever you can to provide information about recognizing and decreasing exposure to asthma triggers. Use the list in this article to make a handout you can leave with the patient or their family. Take the time to point out specific actions they can take while you’re in their home (e.g., “Move the litter box out of your child’s bedroom.”) Your

Breath-Activated Nebulizers Most ALS EMS systems use nebulized beta-agonists to treat patients with asthma attacks. Research indicates that prolonged exposure to these medications may cause increased asthma in respiratory therapists. We recommend that EMS services consider replacing their constant-flow nebulizers with breath-activated nebulizers to decrease their occupational risk from exposure to these medications. moments spent helping them prevent that next attack can keep you from having to make a return call. If you can include family and friends as well as the patient, your efforts will have greater impact. As part of your patient assessment, you should gather information about potential asthma triggers that may have caused this particular attack, and any recent illnesses and medication changes. You should also get a feel for your patient’s compli-

service might even offer to provide asthma-trigger home inspections, like you do for fire prevention or fall prevention among the elderly. Consider hosting asthma attack prevention education at your station or headquarters, like you do for CPR. With nearly one in 10 Americans having been diagnosed with asthma, you’ll have a steady supply of students. Since more kids have problems with asthma than adults, consider providing asthma prevention 218

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Nearly 31 million Americans—more than one in 10—have been diagnosed with asthma sometime during their life. According to the National Heart, Lung and Blood Institute, the cost of asthma in 2000 was $13.8 billion. education to schools in your area. Consider making regular contact with your sickest asthma patients and their families to support their selfcare. Ask them about their peak flow meter readings and remind them to take their medications, wash their sheets and drink enough fluids. We believe that with proper education and support, people with asthma can lead happier, healthier and more active lives that are free from ambulance rides and emergency department visits. Tom Wagner, chief operating officer of the EMSA system in Oklahoma, says an asthma case was the worst call of his life. “It was a 16-year-old boy who was having an asthma attack while playing in a high school basketball game,” Wagner

says. “Apparently he kept playing, even though he was having trouble breathing, until he couldn’t take it anymore and sat on the side of the court. We walked in with all the people in the bleachers watching us. He was moving almost no air. Even though it was more than 18 years ago, I can still see his eyes as he looked at me and died. If there’s anything we can do to prevent that from happening to other people, we should do it.” Special thanks to Chad Council for allowing us to share his description of an asthma attack at the beginning of this article. His asthma is now under good control, and he’s an active member of an urban search and rescue team.

Laurie Romig, MD, FACEP, is medical director for Pinellas County (FL) Emergency Medical Services. She’s had asthma since her emergency medicine residency; however, she’s controlled it well enough that she’s never had to call EMS or visit the emergency department. Mike Taigman is a lifelong student who is committed to helping EMS systems become better stewards of the health of the communities they serve. He has not had an asthma attack since he was 15 years old, and that was a long time ago. Contact him at www.miketaigman. com.

Resources Heart, Lung and Blood Institute: www.nhlbi.nih.gov. Download the National Asthma Education and Prevention Program Expert Panel Report 2: Guidelines for the Diagnosis and Management of Asthma at www. nhlbi.nih.gov/guidelines/asthma/asthgdln.htm.

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congestive heart failure By Ronald N. Roth, MD, & Mike Taigman

Living with congestive heart failure (CHF) is not easy, but there are steps EMS providers can take to improve the lives of CHF patients

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he heart is an amazing 10-ounce pump. Each heartbeat squeezes about 2.4 ounces of blood into the circulatory system. At an average rate of 72 beats per minute, 1.3 gallons of blood are pumped every 60 seconds. In a day, that’s 1,900 gallons, almost 700,000 gallons each year. The average 70-year-old heart has pumped over 48 million gallons during its lifetime—enough to fill 68 Olympic-sized swimming pools. When the heart fails to pump as well as it should, fluid backs up and causes congestive heart failure (CHF), which is often the end stage of cardiac disease. Almost five million Americans have CHF and over 400,000 new cases are diagnosed each year. If you’re over 40, there’s a one in five chance that you’ll develop CHF before you die. If you’ve got high blood pressure, your risk will double. If you’ve had a myocardial infarction, your risk for CHF goes up 500%. CHF is the most common primary or secondary diagnosis for all people over 65 who are admitted to the hospital. A third of people discharged from the hospital with CHF are dead within the year and less than 25% are still alive six years after their diagnosis. Over $23 billion is spent each year on the diagnosis and treatment of CHF in America. Data show that 30%–40% of people who are discharged from the hospital with CHF will be readmitted within the next six months. However, research indicates that over 40% of these readmissions could have been prevented. In 9 out of 10 cases of relapse, the precipitating factors can be identified. The main factors include lack of adherence to physicians’ recommenda-

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tions, including medication use, uncontrolled hypertension, cardiac arrhythmias, iatrogenic (healthcare- provider caused) and pulmonary infections. Emotional factors such as high stress precede the hospitalization of 49% of people with CHF.

CAUSES OF HEART FAILURE The most common causes of CHF are ischemic heart disease, myocardial infarction, hypertension and diabetes mellitus. Less common causes include non-ischemic dilated cardiomyopathy, alcoholic cardiomyopathy, HIV-related cardiomyopathy, myocarditis associated with infection, valvular heart disease and chronic arrhythmias. There are many ways to classify CHF, including systolic (that which is caused by the inability of the ventricle to contract fully) and diastolic (the impairment of ventricular relaxation and filling). CHF can also be classified as left or right heart failure. Left heart failure causes congestion in the lungs with pulmonary symptoms including shortness of breath, orthopnea (shortness of breath when lying down) and nocturnal coughing. Left heart failure also causes fatigue, confusion, memory problems and diaphoretic, cool extremities. Right heart failure causes a backup of fluid in the rest of the body, which results in peripheral edema, ascites (fluid in the abdominal cavity) and a swollen liver.

FUNCTIONAL CLASSIFICATION OF CHF Many cardiologists use the New York Heart Association’s functional classification of CHF to describe the severity of the disease in a particular patient. 220

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Simulating Congestive Heart Failure Have you ever tried a virtual-reality ride at an amusement park? You climb into a little pod, hang on to the seat in front of you and participate in a variety of thrilling situations. These rides use a combination of video, sound and motion to create what feels like a real experience. Well, there’s a new virtual-reality experience that’s making its way around the country, but you’re not likely to find it at the local amusement park—instead, you’ll find the Heart FXPOD at medical schools and hospitals. The Heart FXPOD is a 5½-minute multisensory simulation that gives you “virtual” congestive heart failure (CHF). As you experience tachycardia, fatigue and shortness of breath, you hear the voices of real patients and their family members describe what it’s like to live when your heart can’t do what it used to be able to do. This simulator is designed to help healthcare professionals better empathize with and care for people whose hearts are deteriorating. The Heart FXPOD is currently in the middle of a 63-city tour of the nation’s leading centers for cardiovascular care. For more information, visit www.heartfxpod.com.

Studies show that 50% of CHF patients do not follow the discharge instructions they receive when they leave the hospital. It’s common for people to run out of their medications, forget to fill their prescriptions or not have enough money to buy their medications. www.emsresponder.com ■ EMS ■ AUGUST 2006

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Class I Patients with cardiac disease who have no limitations to their physical activity. Physical activity does not cause undue fatigue, palpitations, shortness of breath or chest pain.

Class II These patients with cardiac disease have slight limitation of their physical activity. There are no symptoms at rest. Ordinary physical activity results in fatigue, palpitations, shortness of breath or chest pain.

Class III Patients with cardiac disease resulting in marked limitation of physical activity. These patients are usually asymptomatic at rest. Less than ordinary physical activity causes fatigue, palpitation, dyspnea or chest pain.

Class IV Patients with cardiac disease who have lost their ability to engage in any physical activity without discomfort. Symptoms may be present while at rest. Any physical activity increases discomfort. While the onset of CHF can be acute, more often than not exacerbations of CHF are preceded by more subtle clues such as worsening shortness of breath with activity; increasing weakness or tiredness; increased swelling in the ankles or lower back; orthopnea, where more pillows are needed to prop a sufferer up to sleep at night; paroxysmal nocturnal dyspnea (PND), where the patient wakes up in the middle of the night gasping for breath; increased need to urinate at night; and fainting or dizzy spells. Usually when folks with CHF call EMS it’s because they can’t breathe, have chest pain, and/or they are exhibiting the confusion or nervousness with diaphoresis associated with cardiogenic shock. Our treatments, which are geared to clearing fluid from patients’ lungs, decreasing their pain and increasing overall perfusion, can have a profound and immediate impact on how they feel. Most EMS systems use a series

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of treatments and medications to decrease the load on the heart. Some systems use continuous positive airway pressure (CPAP) to help push fluids out of the lungs. These interventions are good and in many cases lifesaving, but much more can be done. EMS systems have the poten-

tial to provide support and monitoring to patients with CHF, which could decrease episodes of exacerbation. Research shows it is possible to reduce hospitalizations from CHF by 50% and the length of stay for those who are hospitalized by 90% with support and facilitated self-monitoring.

How You Can Educate CHF Patients EMS providers are in an ideal position to educate patients about ways in which they can improve their health. • Exacerbations of CHF are usually preceded by weight gain. Patients with CHF should climb on a scale every day at the same time and then record their weight. An increase of 3–5 pounds in a week is a signal that the patient may be heading for trouble. • Uncontrolled hypertension, defined as a diastolic blood pressure of 105 mm Hg or more, has been identified in more than 40% of CHF patients who were readmitted to the hospital. Patients need to regularly monitor their blood pressure and see their physicians if it’s too high. • It’s important for patients with CHF to eat a low-sodium diet, which equates to less than 2–3 grams a day. There’s a gram of sodium in one slice of pepperoni pizza. Other high-salt foods that should be avoided include lunch meats, cheese, canned soups, bacon, salted nuts, potato chips, sauerkraut, pickles, olives, smoked meats and fish, diet soda, soy sauce, prepackaged dinners, dried soup mixes and salad dressings. • Patients with CHF should avoid taking non-steroidal anti-inflammatory drugs (NSAIDs) like aspirin, Motrin, Advil, naproxen, Naprosyn, Aleve and ibuprofen. These medications block the effects of diuretics and ACE inhibitors, which are used to treat CHF. In one study, there was a 200% increase in hospitalizations for CHF patients taking NSAIDS and diuretics. • Patients with CHF need to be careful when using herbs, vitamins and alternative supplements, as many of these can interfere with or potentiate the medications used to treat CHF. Hawthorn berries, which people take for cardiovascular disease, high blood pressure, high cholesterol and insomnia, can be dangerous to patients taking prescription medications. Licorice and licorice extracts, which people take to improve digestive health, can increase high blood pressure. St. John’s Wort, which people take as an antidepressant, interferes with levels of Digoxin and warfarin in the blood. One study showed that 45% of patients with CHF were taking some kind of herb or alternative supplement. • Psychological stress has been reported by 49% of CHF patients who are readmitted to the hospital. Yes, when your grandmother says, “Don’t do that, you’ll put me in the hospital,” she may have been right. • Patients need to comply with the discharge instructions they receive from their physicians when they leave the hospital. Studies show that 50% of CHF patients do not follow these instructions. It’s common for people to run out of their medications, forget to fill their prescriptions or not have enough money to buy their medications. Research also shows that older patients, smokers and those with diabetes are least compliant with their discharge instructions.

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WHAT CAN EMS SYSTEMS DO? Patients with CHF who have called 9-1-1 should be treated according to local protocols. Some patients will be too ill to provide you with a good history, but for those who can communicate, a thorough, detailed history should be gathered. Ask about the things that could have caused the exacerbation, including taking NSAIDs or alternative supplements, emotional stress, excess salt in their diet and failure to properly take their medications. EMS systems might consider “adopting” some of their patients with CHF. Calling patients on the phone each day, asking them how they feel, their weight, if they have taken their medications and if they have enough of their medications could provide them with the support necessary to comply with their treatment plan. If the patient has a blood

pressure device, we could also record their blood pressure over the phone. Alternatively, some systems could encourage patients to drop by the station to have their blood pressure and weight checked. A few EMS systems may even want to provide home visits where they check medication supply, weight and blood pressure. Recording patients’ daily weight and blood pressure allows us to track the progress of their disease and intervene before their lungs fill with fluid. If a patient is gaining weight, their blood pressure is increasing, or they are running out of their medications, EMS folks monitoring them have several options. They can tell the patient to contact their physician. They can, with the patient’s permission, contact the patient’s physician on their behalf to report their findings and discuss what needs to be done. They can transport the patient to the physician’s office or hospital for further evalua-

tion. Their physician should determine the weight and blood pressure alarm points that would cause action. With the proper support, it is possible that people with this diagnosis will stay out of the hospital, live longer and feel better. Isn’t that why we got into this business in the first place? Ronald N. Roth, MD, is an associate professor in the department of emergency medicine at the University of Pittsburgh School of Medicine and medical director for Pittsburgh EMS. Mike Taigman is a lifelong student who works with EMS systems worldwide, helping them improve the services they provide. Contact him via www.miketaigman.com.

To hear more from Mike Taigman on this series, listen to his podcast interview on EMSResponder.com.

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pain management By Arthur Kanowitz, MD, & Mike Taigman

Part 6

Can we deliver all our patients to the hospital pain-free?

Photo by Dan Limmer

“We haven’t got time for the pain.”

—Carly Simon

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ain management is one of the oldest aspects of medicine. Hippocrates wrote about the pain-soothing effects of willow bark and leaves in 400 B.C. Opium was cultivated for pain management long before that. Using the active ingredients in these traditional remedies, aspirin and morphine were isolated in the 1800s, providing the foundation of the modern pharmaceutical industry. While some progress has been made in EMS pain management over the last few years, we believe the time has come to set a bold national goal: Deliver all EMS patients to hospitals pain-free. Some may say this goal is neither possible nor reasonable. Is Medtronic’s vision of “a world in which no person dies suddenly as a result of a cardiorespiratory event” reasonable? Reasonable people will not make great improvements in EMS. Great improvements

will be made by compassionate and patient-centered people committed to doing what others say can’t be done.

PAIN’S VITAL PURPOSE Physical pain is not a primary disease; it is a symptom of a disease or injury. It serves a vital purpose in our survival. It’s our body’s way of telling us to yank that used IV needle somebody left on the bench seat out of our butt. Pain is our inspiration for calling 9-1-1 in the middle of the night when our coronary arteries clog from one too many extracheese pizzas. It’s what keeps us from doing more damage by climbing back on our mountain bike with a broken femur. Once pain has sounded the alarm and prompted a person to take action, it has served its primary purpose. Its secondary purpose is to remind us not to do things that aggravate the problem. Anyone who has taken a hot www.emsresponder.com ■ EMS ■ OCTOBER 2006

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What is Pain? The experience of pain is always subjective. Each person learns about pain through bumps and bruises early in life. It starts with the receptors at the ends of nerves in the skin, muscles, bone, blood vessels and some internal organs. These receptors detect a potentially harmful stimulus. A message travels along the nerve to the spinal cord, which gets activated. The activated spinal cord sends the information to the brain and a signal to the muscles near the site of the pain to contract and move away. The message arrives in the brain and is sent to several areas that control physical sensation, emotional feeling and cognitive thinking. According to the American Academy of Pain Management, “Pain is complex and defies our ability to establish a clear definition. Pain is far more than neural transmission and sensory transduction. Pain is a complex mélange of emotions, culture, experience, spirit and sensation.” Pain threshold is the lowest level of pain a person can recognize. Some folks have a low pain threshold, as in the fairy tale of the princess and the pea, in which the princess found the slightest discomfort of a pea under her mattress so unbearable as to prevent her from sleeping. Pain tolerance, on the other hand, is the greatest level of pain a person can tolerate. A friend just gave birth to twins, each of which weighed more than 6½ pounds. In the delivery room after hours of hard labor, her hus-

shower with a sunburn or tried to carry a 270-pound patient down the stairs before their torn back muscle was fully healed has experience with this benefit. Pain researcher Thomas J. Romano, MD, PhD, says, “When pain is no longer of value in warning the patient that there is a problem, it can become the problem.” According to the American Medical Association, pain of all types is undertreated in

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band, a lifelong martial artist, concluded, “No man could take this level of pain.” There are several different ways to describe and classify pain. These four categories are useful for EMS professionals:

Somatic pain This type of pain is sensed by nociceptors, which are sensory neurons found in external tissues such as the skin, corneas, joints, muscles and bones. The pain of a fractured wrist, a scratched cornea or a burned finger is somatic pain. This type of pain tends to be localized and may respond to cold packs, nonsteroidal anti-inflammatory drugs, acetaminophen, opioids and/or local anesthetics.

Visceral pain This is the type of pain that occurs when our internal organs are damaged. The internal organs that have nociceptors are mostly the hollow viscera, the gut, the bladders and the uterus. Kidney stones, irritable bowel syndrome and dysmenorrhea are common causes of visceral pain. This type of pain tends to be generalized, diffuse and difficult to locate. It is most responsive to opioid therapy.

Neuropathic pain This type of pain is difficult to understand and treat. Rather than the nervous system functioning properly to sound an alarm regarding tissue injury (as with somatic and visceral pain), in neuropathic pain the peripheral or central nervous system malfunctions and

our society. The pediatric and geriatric populations are especially at risk for undertreatment. The Joint Commission on Accreditation of Healthcare Organizations’ new standards require organizations to screen all patients for pain, ensure competency of their staff in pain management and collect data to monitor the appropriateness and effectiveness of their pain management. They emphasize that appropriate manage-

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becomes the cause of the pain. For example, the phantom pain that people feel in limbs that have been amputated is neuropathic pain. It is also common in people with alcoholism; back, leg and hip problems; cancer; diabetes; facial nerve problems; AIDS; multiple sclerosis and shingles. It may be resistant to opioid therapy. Sometimes it is effectively treated with antidepressants and anticonvulsants.

Breakthrough pain This is a sudden increase of pain in people who already have chronic pain. Most of the literature describes this pain in cancer patients. It is a common reason for EMS to be activated for hospice patients. The undertreatment of this type of severe pain was highlighted by Donald Berwick, MD, president and CEO of the Institute for Healthcare Improvement, when he described the results of a study conducted by the Institute to an audience of more than 7,000 physicians and healthcare professionals. Berwick said that hospice patients transported to hospitals for breakthrough pain waited an average of 110 minutes from their arrival in the emergency department before receiving their first dose of pain medication. He said he considered requiring conference attendees to come naked to his presentation next year and sit on chairs covered with broken glass, tacks and rock salt. “Then,” he said, “I’ll stand here while you sit in pain for 110 minutes.”

ment of patients with pain must be a top priority in healthcare. In EMS there are many strong opinions on the subject of pain management. One medical director who doesn’t want to change his system’s pain-management protocols is fond of saying, “No one ever died from pain.” It is unlikely that this physician has ever experienced severe pain. Some EMS systems are worried about drug seekers and addicts manipulat225

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ing them to get high. Physicians may worry that field pain management will obscure their ability to properly diagnose a patient once that patient arrives in the emergency department. They also worry that once someone has been given a narcotic for pain, they will not be mentally competent enough to consent to surgery should they need it. Our position is that pain can and should be aggressively managed in the prehospital setting. When you look at the reasons people call 9-1-1 for medical problems, pain is part of the picture more than half the time. If you ask EMS customers what they

Figure 1

want from their EMS service, they’ll tell you “Get here fast, make me feel better, make my pain go away and take me to the hospital.” Pain is one of the primary reasons people call us, yet in most EMS systems pain management is approached the way third-graders approach cleaning their rooms. They know they have to do a little bit, but it’s not a high priority, and there are other things they’d rather do.

WHY PAIN IS UNDERTREATED What gets in the way of adequate pain management in EMS and the

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rest of emergency medicine? Folks in EMS tend to have strongly held beliefs about pain. Many of these beliefs do not match the research or the expert opinions of pain-management specialists. Examples of these beliefs include the medical director who said, “No one ever died from pain.” Another is the paramedic with 31 years of experience who said, “I can tell when someone is really hurting and when they’re just using me to get high.” Or the veteran paramedic who said, “You don’t understand—this area is packed with junkies and tweakers. You want me to give them more morphine? Don’t you know these people are addicts?” Or the emergency physician who said, “If you treat someone’s abdominal pain, it will interfere with the diagnosis, possibly delaying treatment. And if they’ve been given narcotics and need surgery, we’ll have to wait for it to wear off or give them Narcan so they can consent.” In an article published in the April 2004 Annals of Emergency Medicine, researchers Timothy Rupp and Kathleen Delaney found that a review of ED pain-management practices “demonstrates pain treatment inconsistency and inadequacy that extends across all demographic groups. This inconsistency and inadequacy appears to stem from a multitude of potentially remediable practical and attitudinal barriers that include (1) a lack of educational emphasis on pain management practices in nursing and medical school curricula and postgraduate training programs; (2) inadequate or nonexistent clinical quality management programs that evaluate pain management; (3) a paucity of rigorous studies of populations with special needs that improve

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pain management in the emergency department, particularly in geriatric and pediatric patients; (4) clinicians’ attitudes toward opioid analgesics that result in inappropriate diagnosis of drug-seeking behavior and inappropriate concern about addiction, even in patients who have obvious acutely painful conditions and request pain relief; (5) inappropriate concerns about the safety of opioids compared with nonsteroidal anti-inflammatory drugs that result in their underuse (opiophobia); (6) unappreciated cultural and sex differences in pain reporting by patients and interpretation of pain reporting by providers; and (7) bias and disbelief of pain reporting according to racial and ethnic stereotyping.” If this is how pain is managed in our emergency departments, it’s unlikely that EMS is in better shape.

PAIN’S CONSEQUENCES Untreated pain has real consequences for patients above and beyond emotional and psychological suffering. Abdominal pain causes voluntary and involuntary splinting of respiratory muscles. If left untreated, this splinting can result in pooling of secretions, which promotes the development of pneumonia and atelectasis. While opioids effectively decrease abdominal pain, they do not decrease localized tenderness, so diagnostic exams are not impaired. Actually, diagnosis is enhanced because effective pain management decreases abdominal muscle guarding, thus allowing for more effective palpation. In five prospective randomized, controlled studies, four of which were double-blinded, researchers found that providing analgesics decreased pain more than localization of tenderness. Thus, none of the studies found compromises in diagnosis or treatment of the acute abdomen after increasing the use of analgesia. A person’s ability to provide informed consent is determined by his or her ability to understand the need for treatment and the risks and options for treatment, not by what 226

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medications the person has been given. It is rare that the amount of medicine needed to manage pain would be so great as to materially impair cognitive function. In fact, severe pain impairs a patient’s ability to listen and understand and may interfere with the informed-consent process. Withholding pain medication until consent is obtained may be viewed as making the patient give permission for procedures against their will.

mean narcotics should not be used to treat a person’s pain. Unfortunately, many healthcare providers tend to undertreat pain in this population, which may have the effect of increasing their use of illegal drugs. Most clinicians believe that their years of experience working with people in pain increases their ability to assess a person’s level of pain and identify people who are intentionally deceiving them. But studies show that clinicians

It is reasonable for EMS systems to have the goal of delivering their patients to emergency departments pain-free, or with dramatically reduced levels of pain. Myths surround addiction and the administration of analgesia. It is important to start with a clear understanding of what is and is not addiction. Addiction is a primary, chronic neurobiological disease with genetic, psychosocial and environmental factors. It is characterized by behaviors that include an inability to control drug use, compulsive drug use, continued use despite harm, and drug craving. Physical dependence is a state of adaptation that includes drug-specific withdrawal syndrome. It can be caused by stopping drug use abruptly, rapidly reducing the dose and/or administration of a drug-specific agonist. This can occur in patients who have been taking aroundthe-clock narcotics for as little as two weeks, but it is not addiction. Tolerance is a state in which exposure to a drug induces changes that result in the reduction of one or more of the drug’s effects over time. Too often, healthcare professionals incorrectly assume that the development of tolerance is an indicator of addiction. It is an indication that in a therapeutic setting, increased doses of the drug will be necessary to achieve the desired effect. One of the dynamics of inadequate pain management is pseudo-addiction. This is where people use manipulative behavior to obtain pain medication because they hurt. Research indicates that when opioids are used to treat acute and chronic pain, the incident of addiction is less than 0.3%. One study evaluated more than 12,000 hospitalized patients treated with opioids for pain and found only four of them were addicts. Another way that patients can decrease their chances of receiving adequate pain management is to request specific drugs. Imagine an African-American teenager complaining of severe pain from a sickle cell anemia crisis asking for morphine. For some healthcare providers, this would be a red flag for drug abuse. But the proper EMS treatment for a sickle cell crisis is high-flow oxygen, IV fluids and morphine. If a patient has had a crisis in the past, chances are, they know what works for them. We should thank them for the information and act on it, rather than judging them as a drug seeker or addict. Alcohol or drug abuse does not interfere with a person’s ability to experience pain and should not prohibit pain management. A history of addiction doesn’t necessarily

who pride themselves on their ability to assess pain levels and identify folks who are faking often turn out to be the poorest judges of other people’s pain.

PAIN MANAGEMENT STRATEGIES Effective pain management begins with a detailed assessment. All pain is subjective, and research shows that the only reliable rating of pain severity is the patient’s own description of how bad it hurts. The use of a 1–10 numerical scale is common, with 1 representing no pain and 10 being the worst pain the person has ever experienced. It’s helpful to ask a person what their worst pain experience was to help understand the number they give. For children and some adults, the face rating system (see Figure 1) may be more effective. In addition to severity, EMS personnel should assess the pain’s location, characteristics and onset time, what makes it better, what makes it worse and what the patient has already done to try to relieve it. Pharmacology is the most common and effective way to treat most types of pain. Pain medications work by blocking the production and/or transmission of the pain signal within the body. Opioids, including morphine and fentanyl, are the analgesics most commonly used in EMS. Demerol (meperidine) should not be used anymore. It is the most toxic of the opioids and can cause confusion, tremors and seizures. Morphine has been used in EMS for more than 35 years. It is a narcotic analgesic that acts as a central nervous system (CNS) depressant by binding to and activating the u-opioid receptors in the CNS. Activation of these receptors is associated with analgesia, sedation, respiratory depression and euphoria. Morphine also acts as a mild peripheral vasodilator. For prehospital pain management, it is typically given intravenously in doses of 2–5 mg aliquots. For pediatrics it is given in 0.2 mg/kg doses. When given intravenously, morphine has a peak action at 5–10 minutes and a clinical duration of action of 2–3 hours. Fentanyl is the newer opioid analgesic in EMS. Like morphine, fentanyl binds with opioid receptors in the central nervous system, causing analgesia, sedation and respiratory depression. However, fentanyl causes less respiratory depression than morphine and has a minimal effect on peripheral vasodilation, and thus a minimal risk www.emsresponder.com ■ EMS ■ OCTOBER 2006

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of hypotension. Fentanyl is given intravenously in 1–2 mcg/kg doses. It is a rapid-acting (<5 minutes) analgesic with a short half-life (90 minutes) and therefore is ideal for prehospital use. It has been found both safe and effective for prehospital pain management. Nitrous oxide is also an analgesic that has been used in the field

ing sedation in pain management. The synergistic effects of the narcotic and benzodiazepine can lead to sedation that’s deeper than intended. Therefore, anyone administering sedation in pain management must be appropriately trained and certified in procedural sedation and capable of providing advanced life support airway management. Patients must be

improve the care and service they provide. His experience with pain has been limited to fighting systems that do not really want to take good care of patients, and a couple of kidney stones. Contact him at www.miketaigman.com.

There is no physical pain known that does not have the potential to respond to appropriate interventional therapy. for many years, but not widely. It is delivered as a mixture of nitrous oxide and oxygen, typically in a 50% nitrous/50% oxygen mixture. Like morphine and fentanyl, it is a CNS depressant. It is typically self-administered: The patient holds a mask over his or her face and breathes deeply. The mask should not be strapped on. If a patient becomes too sedated, they will drop the mask, preventing significant overdosing. Nitrous must be used with caution: It is 34 times more soluble than nitrogen. It will diffuse into areas of trapped gases and can cause increased pressure and tissue damage. Therefore, it should not be used in cases of pneumothorax and intestinal obstruction. Frequently it is necessary to combine a narcotic (analgesic) and a benzodiazepine (anxiolytic) to provide adequate pain management. Administration of a narcotic with a benzodiazepine has historically been considered conscious or procedural sedation and analgesia. For pain management, we like the term sedation, which describes a reduction in the degree of anxiety, pain and awareness a patient may experience during a painful illness or injury. The patient should retain their ability to maintain a patent airway independently. They should maintain their protective reflexes and their ability to respond appropriately to physical stimulation and/or verbal commands, and should remain easily arousable. Care must be exercised when administer-

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appropriately monitored with EKG, pulse oximetry and capnography. High-flow oxygen therapy has been found to provide significant pain relief to the majority of cluster headache sufferers. Cluster headaches are an intense, severe affliction characterized by brief and frequent attacks. Some systems are experimenting with other pain-management techniques, such as acupressure, guided imagery and therapeutic touch. There is not enough data to recommend them for EMS use at this time. The bottom line is that there is no physical pain known that does not have the potential to respond to appropriate interventional therapy. It is reasonable for EMS systems to have the goal of delivering their patients to emergency departments pain-free, or with dramatically reduced levels of pain. While it is true that this goal may not be achievable 100% of the time, it is something to work toward. As physician, humanitarian and Nobel Peace Prize winner Albert Schweitzer said, “Whosoever is spared personal pain must feel himself called to help in diminishing the pain of others.” Arthur Kanowitz, MD, is an emergency physician, EMS medical director, paramedic, researcher and innovator. He has firsthand experience with severe pain. He was also Mike Taigman’s EMT instructor in 1976, which may have been somewhat painful. Mike Taigman is a lifelong student who works with EMS systems worldwide, helping them

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An Emerging Role for EMS

Instead of scrambling to keep up with all those 9-1-1 calls, how about getting out in front of them, and stopping them before they happen? That’s not traditionally been the role of EMS—we’re reactive, not proactive—but in this special section, we examine how it could be. With a greater embrace of the public health component of their roles, EMS providers can help people identify and better manage their conditions and diseases and make healthier choices in their lives. This can improve their overall well-being and reduce the frequency with which they require our services. As you read the following articles, consider how ideas like these might apply to your service. 229

By Sascha Liebowitz & Mike Taigman

Advocates for Health Emed Health turns to EMS for patient education, disease management Two years ago, EMS Magazine published a series of articles titled Taking EMS Into Tomorrow (May–Oct. 2006). It generally promoted the idea of EMS providers serving in a public health capacity, assisting with things like injury prevention and disease management and education in addition to providing emergency care. The series generated a lot of feedback— everything from excitement from systems wanting to engage in such community service to cynicism from those who thought EMS should stick to its traditional business of dropping tubes, shocking hearts and hauling folks to the hospital. Well, while the debate rages on, there is a group of pioneers in Pittsburgh who are turning the vision of EMS-facilitated illness prevention and chronic disease management into reality with what they call “emergency medicine-based health promotion.” Emed Health, part of the Center for Emergency Medicine of Western Pennsylvania, Inc., is actively blending EMS with chronic disease management, health promotion and prevention. According to Executive Director Kelly Close, MD, MPH, “Emed Health’s goal is to take healthcare to people where they live and work and empower them with the tools, systems and knowledge to prevent and manage their own health and chronic diseases.” Emed Health is doing all the things the cynics said couldn’t be done. Here’s how these pioneers are doing it.

‘THE EMS MODEL’ Emed Health uses what it calls the “EMS model,” which entails subcontracting with local EMS organizations to provide services to people in their communities. EMS providers are suited for this role because they are well-integrated into the communities they serve and can be an underutilized healthcare resource, especially in rural communities. Emed Health provides the training, patient programs, contracts for services with payers, data tracking and analysis,

and quality management systems. The subcontracting model prevents Emed Health from competing with EMS agencies for providers, allows the agencies to determine when and how they will become involved, enables use of agencies’ existing malpractice and worker’s compensation policies, and provides a scalable model with few fixed costs, since services are only contracted for when there is work. This leads to lower costs to payers and patients and makes it cost-efficient to provide personalized healthcare prevention and disease management services in the community and in patients’ homes. Emed has contracts with insurers, employers and hospitals to deliver services, which means a sustainable source of income for EMS agencies. It also creates alternative career opportunities within the existing system for EMS personnel who enjoy public health, education and continuity of care, especially if they are among the 27% of providers who leave EMS each year due to injury, burnout or an inability to meet the field’s physical demands. Part of the Emed Health vision is that EMS can become

stay healthy. From a financial perspective, it is less expensive to prevent and manage complications of chronic diseases than it is to treat them over and over again as emergencies. “We started getting involved with injury prevention at the university, and it got me thinking about prevention in general,” says Paul Paris, MD, FACEP, chief medical officer of the Center for Emergency Medicine (a multihospital consortium in western Pennsylvania dedicated to advancing emergency medicine) and one of the creators of Emed Health. “I started reading about health promotion and wellness and was dumbfounded to discover that 70% of healthcare dollars are spent on caring for patients with chronic diseases, such as asthma, congestive heart failure and diabetes. When you buy a GM car, $1,700 goes toward healthcare costs— more than the cost of the steel in it.” Anne Boland Docimo, MD, MPA, chief medical officer for the University of Pittsburgh Medical Center (UPMC) Health Plan, says programs such as Emed Health’s diabetes prevention and asthma management programs can offset the rising costs of hospital care. “The more

Emed has contracts with insurers, employers and hospitals to deliver services, which means a sustainable source of income for EMS agencies. a place where people can still work even when they can’t lift stretchers anymore. Through prevention, wellness promotion and chronic disease management, Emed creates an interesting alternative career path for EMS professionals while improving the healthcare system for patients and payers alike. Emed Health is finding that its patient customers are visiting emergency departments less often and have improved quality of life. The EMS “health advocates” trained to implement the programs get a lot of satisfaction from helping people

patients who receive education on how to manage chronic illness, the fewer patients there will be who develop complications and have higher healthcare costs down the road,” Docimo says. Here are some of the pioneering programs Emed Health is currently developing. Input from the medical community and the general public is always welcome at www.emedhealth.com.

ASTHMA According to Rodney Jones, vice president of operations for the UPMC’s

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Braddock Hospital, the health disparities in his area are among the worst in America. “We fall below the county, country and world in cardiovascular disease, infant mortality, diabetes and asthma,” Jones says. Braddock is the main healthcare provider for a population in which one third of children and half of adults live in poverty. Three quarters of the hospital’s patients come in through the emergency department. Nationwide, 5%–7% of children suffer from asthma. In the neighborhood served

Emed also helps with logistical considerations that are often barriers to optimal care. For example, EMS health advocates help patients who have trouble paying for their medications find programs that can assist. They also help them fill out forms for free transportation services so they can see their physicians or get prescriptions filled. As an EMT for nearly 18 years, Becky Miller treated people with broken legs, heart conditions and dog bites. Recently, she joined the Emed Health asthma dis-

Participants in the program get to make a difference in people’s lives in a way many medical providers don’t. by Braddock, it’s 25%. Poverty contributes to the problem, combined with lots of smokers and deplorable living conditions. “We have a large number of asthma patients who come to the emergency department every week,” says Jones. “For those who have insurance, 80% are covered by Medicare or Medicaid, and they won’t cover people who return to the hospital within 30 days of their last visit.” Emed Health created an in-home asthma management program to help Braddock’s patients better manage their disease. Emed trains paramedics and EMTs from local EMS services to administer the asthma program. The program consists of several home visits in which patients are provided education on their disease, proper use of peak-flow meters, spacers and medications, management of environmental triggers, interacting with physicians and developing action plans, and are given program assessment tools such as satisfaction and quality-of-life surveys.

ease management program as a health advocate. “The woman I was working with learned she was taking her medicine wrong—she was totally amazed,” says Miller. “She also didn’t know she had triggers in her house, like dust and mold.” Twenty-five patients have been through the program so far. According to one, “I’m not sure I’d still be alive were it not for these people helping me. They taught me how to take care of myself much better than the doctor. I’ve had asthma most of my life, but it’s been getting real bad the last few years. I was going to the emergency department once or twice a week. Since they helped me take better care of myself, I haven’t been once.” John, a paramedic with the local Guardian Angel Ambulance Service, says, “Most patients never really learned how to use their peak-flow meters. We take the time to teach people.” EMS providers enjoy helping their “frequent fliers.” By their providing these patients with the skills necessary to

Table I: Mike Parlak’s Screening Results Weight Body Mass Index (BMI) Blood pressure Waist circumference Triglycerides Glucose HDL

Initial screening 3-month screening 233 lbs. 175 lbs. 36* 25* 123/91* 118/62 46 inches* 33 inches 147 mg/dl 89 mg/dl 104 mg/dl* 85 mg/dl 45 mg/dl 47 mg/dl * Indicates a risk factor for diabetes

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care for their diseases, the patients stay healthier, the EMS system runs fewer calls, and the hospitals provide less uncompensated care. Jones says it’s better for him financially to pay Emed Health to provide this service for his asthma patients. “It costs us less to provide this program than it does to provide unreimbursed emergency department care to these patients,” he says. “We have a commitment to addressing the healthcare disparity in our community. About half of my 700 employees live in this community. Using a unified approach with our employees, 50 other community groups, faith-based organizations and patients, we are going to make this a healthier community.” Results of the asthma program for uninsured patients have been positive. Patients get surveys at intake and at the end of the home visits. The same survey was also mailed to patients six months after the home visits. A validated Risser satisfaction survey was also administered anonymously at the end of the home visits. At the beginning of the study, 60% of participants reported being in an emergency department in the last six months for an asthma-related visit. Three months after starting the program, that figure had dropped to 10%. Similarly, at the beginning of the study, 36% had been hospitalized overnight for asthma-related illnesses, but after three months that figure was down to 5%. The satisfaction survey results indicate that participants found great value in the services they received. All patients agreed that their EMS health advocate was understanding in listening to their problems. Patients strongly disagreed that their EMS health advocate was too busy to spend time talking with them, which is a common complaint of patients following traditional healthcare visits. Overall, patients reported they were extremely satisfied with the disease management program.

DIABETES In 2004, approximately 23,000 Pennsylvanians were hospitalized for diabetes-related problems, costing about $673 million. Emed Health modified the National Diabetes Education Program 231

Other Resources www.cdc.gov—The CDC has information on vaccination recommendations, health screening guidelines and chronic disease management. www.welcoa.org—The Wellness Councils of America offers information about the costs and benefits of health programs in the workplace. www.dmaa.com—The Disease Management Association of America. www.nchec.org—The National Commission for Health Education Credentialing offers training and credentialing for health educators. http://web.ncqa.org—The National Committee for Quality Assurance is dedicated to developing quality standards and measurements for healthcare entities. www.motivationalinterview.org—Resources for clinicians, researchers and trainers on how and when to use this technique to motivate behavior change. to help keep front-line emergency workers and their families from developing this deadly disease. The program’s initial focus was on the personnel and families of EMS, fire and police departments. Participants for the intervention group were recruited from two rural counties that had among the highest rates of diabetes in Pennsylvania. To qualify for the study, participants had to have metabolic syndrome, consisting of an elevated body mass index plus at least three of the following: 1) elevated glucose (but not yet diabetic), 2) high blood pressure, 3) abdominal obesity, 4) low HDL (good cholesterol) and 5) high LDL (bad cholesterol). Fifteen intervention group members participated in 12 classes (taught by EMS health advocates who went through the National Diabetes Education Program curriculum) and were given free gym memberships. During these classes the public safety workers learned about diabetes prevention, such as how to eat right, use a pedometer, exercise regularly and utilize a food diary to track their intake. Eight control group members received information and free gym memberships, but no classes or health coaching. All participants were screened three and six months after starting the program. Although six-month results have yet to be measured, at three months the mean weight loss was 16.1 lbs. in the intervention group and 11.3 lbs. in the control group. One patient, police officer Mike Parlak, is much less likely to develop diabetes since completing Emed Health’s prevention program (see Table I). Parlak knew he was overweight and had high cholesterol, but didn’t know he had an

elevated fasting glucose level and several other risk factors that increased his chances of diabetes. “My doctor had been after me to lose weight and exercise more, but I had no idea I was at such high risk for developing diabetes,” Parlak says. “The classes were really helpful—no one was judgmental, and we were all very comfortable discussing our progress. The best part was getting weighed each week. I loved to see the results of my hard work paying off.” Three months later, Parlak has lost weight and lowered his blood pressure, cholesterol and fasting blood sugar, significantly reducing his odds of becoming a diabetic. He’s gained knowledge he’ll be able to use for a lifetime. “I weigh myself every day,” he says. “If I see my weight creeping up, I exercise a little longer and eat a little more carefully. “A little work and education about proper eating habits and dedication to the program can change lives,” Parlak adds. “I honestly feel better, have more energy and enjoy doing all the activities that were difficult for me when I was overweight and out of shape.” Once the final results of the program within the EMS and public safety community are available, Emed Health hopes to implement the program more widely in other businesses and systems.

HEALTH & WELLNESS Some of Emed Health’s programs’ most important work has been in identifying atrisk individuals so they can be educated about changing their behaviors before they develop serious diseases. The majority of the health screenings have been performed in partnership with the UPMC

Health Plan. Emed has provided glucose, blood pressure, cholesterol and carbon monoxide testing for more than 17,000 people in the last year through this program. The success of these screenings has in large part been due to the vision and coordination of the UPMC Health Plan, one of the top-ranked health insurance programs in the country. The program’s top officials recognize that health promotion saves money by improving retention, morale, turnover and productivity rates. Rose Gantner, EdD, the UPMC Health Plan’s senior director of health promotion, says a roughly 3:1 return on investment in health education can be expected in about two years, mostly from decreased absenteeism and turnover, but also from reducing the number of sick and unhealthy people who come to work anyway and perform suboptimally. For more information about the value of health promotion in the workplace, see the Wellness Councils of America’s website, www.welcoa.org. Gantner says that “Sixty percent of all illness can be changed with lifestyle modifications. Physical, mental, emotional, spiritual, occupational and family dimensions all can impact health. We have found that 80% of health plan dollars are spent on people who are high risk. Our goal is to keep the low- and moderate-risk people from becoming high-risk.” A key part of achieving that goal is identifying those people and educating them before their conditions develop into something more serious. During these screenings, Emed’s EMS health advocates measure body mass index, heart rate, cholesterol, carbon monoxide, glucose, HDL, LDL, triglycerides and blood pressure. Height and weight measurements are used to calculate body mass index (BMI). At the end of the screening session, health educators from UPMC Health Plan provide participants with educational materials and counseling about their risk factors and the need to follow up with their primary care physicians. Patients can have their results sent to these physicians. Participants in the program get to make a difference in people’s lives in a way many medical providers don’t. They’ve helped a pregnant woman with a high CO level find a gas leak in her home, sent cont. on page 12

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By Mario H. Treviño, MPA, CFOD, Lindsay White, MPH, Hendrika Meischke, PhD, & Mickey S. Eisenberg, MD, PhD

A New SPHERE for EMS Supporting public health with emergency responders Since its inception in the late 1960s, fire-based EMS has continually improved upon the original concept of providing rapid response to medical emergencies with trained firefighter/paramedics. Among the first in the United States to implement the concept, the Seattle/King County Medic One system often garners honors for the long-term survival rates of its sudden cardiac arrest patients. Many other excellent models exist, and annual incremental improvements have come to be expected as technology and medical studies further refine the state of the art. Everything from closest-unit dispatching to automated external defibrillators placed in public venues has been employed to help reduce the time needed to answer calls and give lifesaving care to those in need. But what if the very best response time to a medical emergency was actually 0:00? Through the SPHERE program in Seattle/King County, there is a new goal in place: to actually prevent future 9-1-1 calls by identifying potentially life-threatening conditions whenever a patient is seen by responders. Consider these two scenarios: • EMTs evaluate a 57-year-old with a mild allergic reaction. Prior to EMS arrival the patient self-administered diphenhydramine (Benadryl) and has improved upon arrival of fire department EMTs. He is stable on exam, with a mild rash on his arms and trunk. His blood pressure is 170/105 and blood glucose (checked because the patient says he has bouts of low blood sugar) is 182 mg. He says he

Table 1: SPHERE Criteria Inclusion criteria for High Blood Pressure Alert • Systolic BP ≥ 160 • Diastolic BP ≥ 100 Inclusion criteria for High Blood Sugar Alert • Nondiabetics w/BS ≥ 175 • Diabetics w/BS ≥ 300 Exclusion criteria for both alerts • Critical patients • Major trauma • MCI

will follow up with his doctor. The EMTs casually mention to the patient that his blood pressure and blood sugar are both high. But because of his stable condition, the EMTs decide that evaluation in a hospital is not needed. The medical incident report is completed and duly filed. • Same situation, but this time the EMTs not only mention that the blood pressure and sugar are high, but also give the patient a personalized written “High Blood Pressure Alert” and “High Blood Sugar Alert” that strongly advise him to have follow-up for possible hypertension and diabetes. They indicate on the incident report that the alerts were given, and one month later the patient receives a call from the EMS office asking if he has followed up with a physician. Which scenario do you think best serves the patient?

THE SPHERE PROGRAM Every day, EMTs respond to countless medical emergencies. While providers’ top priority is to deal with the immediate problem, stabilize the patient and arrange further appropriate care, they also have opportunities to identify and help control major public health problems. In the second scenario above, the patient’s abnormal blood pressure and blood sugar are discussed, and he is given written, personalized and specific sets of instructions for follow-up. Such practice is now routine in the Seattle/King County metropolitan area. The program is called SPHERE, which stands for Supporting Public Health with Emergency Responders. The sphere represents the concept of obtaining clinical information and feeding it back to the patient in a useful and consistent fashion—a circle of information from the patient to the EMT and back. SPHERE is designed to help identify and control two major public health problems: hypertension and diabetes. Though the program is an expansion of the traditional role EMS personnel play in their communities, it affords the opportunity to have a large impact with little extra effort. EMS

10 OCTOBER 2008 PUBLIC HEALTH PERSPECTIVES www.emsresponder.com

personnel can respond to medical emergencies and simultaneously help fight chronic disease (and possibly prevent future emergency responses). High blood pressure (HBP) and diabetes are two major public health problems. High blood pressure affects 65 million Americans. It is estimated that one third of patients with HBP are unaware they have the condition, and another third inadequately control it. Around 20 million Americans have diabetes (85% have type II diabetes), and another 6–7 million have undiagnosed type II diabetes. Both conditions are major contributors to heart disease, stroke and kidney failure. Since EMTs almost always determine blood pressure as part of routine vital signs, and frequently check blood glucose, they have a unique opportunity to identify new and uncontrolled cases of HBP and diabetes. In this sense the EMS system and its hundreds of thousands of personnel can serve as a virtual cadre of public health advocates. They enter the homes and businesses of a considerable portion of the population every year. In King County, the EMS system responds to approximately 7% of the population annually, many of whom are underserved or without a source of regular medical care.

HOW SPHERE WORKS The inclusion criteria for SPHERE are simple (see Table 1). For blood pressure the criteria are a systolic of 160 or higher or a diastolic of 100 or higher. For diabetes the criteria are a blood glucose measurement of 175 or greater in a nondiabetic patient or 300 or greater in a diabetic. If these inclusion values are found, the patient is given the appropriate alert card and urged to follow up. The patient is also offered the opportunity to have follow-up checks at the fire station. EMTs are encouraged to use judgment when giving alerts; if the scene or situation is too unstable or simply inappropriate, alerts should not be provided. Examples of such situations are critical patients, major trauma, crime scenes 233

Figure 1: High Blood Pressure Alert Card

PILOT PROJECT In order to decide whether EMTs should take on this new role, we conducted a pilot project between January and August 2006. EMTs in two King County fire departments participated. Eligible patients received high blood pressure and/or high blood sugar alerts during their medical incidents (see Figure 1). On the medical incident report form, EMS personnel recorded whether they gave an alert to each patient. The cards also listed a contact phone number for the fire department and numbers for the American Heart Association and American Diabetes Association. During the pilot project more than 250 alerts were distributed, the majority (86%) given for high blood pressure. These patients had an average systolic blood pressure of 175 and an average diastolic of 94. Thirty-five patients (15%) received high blood sugar alerts; they had an average glucose level of 330. Patients who received alerts were called about four weeks after their medical incidents. While the number of high blood sugar patients reached was not large enough to draw any meaningful conclusions, the analysis of high blood pressure patients, drawn from 69 telephone surveys, was extremely encouraging. A majority of the patients interviewed remembered receiving alerts from EMS personnel (74%), and most reported positive reactions to receiving them (85%). Over half of the patients (59%) reported being motivated by their alerts to seek follow-up medical care after their medical incidents. In addition, almost two thirds (62%) of alert patients noted that their alerts influenced them to get their blood pressures checked again. To complement the patient perspective on SPHERE, EMS personnel who participated in the alert interventions were also surveyed. Of the surveys returned within two weeks, an overwhelming majority were supportive of the SPHERE project, noting that it was not difficult to distribute alerts at scenes (77%) and that distributing alerts did not take up an inordinate amount of their time on scene (88%). Open-ended questions on the EMS

Date:____________________

Blood Pressure Categories

EMT: ____________________ Your blood pressure: ________ Systolic: _____________ Diastolic:_____________

High blood pressure can lead to life-threatening disease such as heart disease, stroke or kidney failure. There are effective treatments for loweing high blood pressure. You need to discuss this with a doctor.

Systolic FOLD

not yet controlled by police, and masscasualty incidents.

Your fire department took your blood pressure during your medical emergency. Your blood pressure was very high.

Diastolic

160

Hypertension 100 Stage 2

140

Hypertension Stage 1

120

Prehypertension

90 80

Normal

We recommend that you have your blood pressure checked again as soon as possible. You may be called in a week or two in order to find out how you are doing.

survey yielded in-depth information from the provider perspective. A few respondents noted it was sometimes difficult to remember to give patients alerts, depending on the nature of the call.

NEXT STEPS It is clear from the pilot study that EMS responders have the ability to help in the battle against chronic diseases in their communities, although further study is necessary to determine what works best in different locations. It may be that an alert followed by a personal letter from the EMS agency is more effective than an alert alone. Such a letter could include information about community resources for follow-up and treatment of high blood pressure and high blood sugar, especially for those who are underinsured. The importance of properly training EMTs in this new role of public health advocates cannot be overemphasized. EMTs need to be equipped with background information about these public health problems and given the tools to properly respond to questions patients may ask when they are given alerts. EMTs need to buy into the importance of this program and view it as part of their mission for the program to be successful. Although the pilot study was small, the results show the immense promise of SPHERE. Consequently, the SPHERE concept became part of the 2007 EMT protocols in King County, and all fire departments within the county are participating in the program.

THE POTENTIAL EMTs visit a significant portion of the population in any given year. Though patients call for specific medical problems, there is an opportunity to, with little extra effort, help identify and control major public health problems. Blood pressure determination is a routine vital sign and part of virtually every patient’s workup; thus high blood pressure values are readily and easily identified. Glucometry and blood sugar determination is not authorized throughout the EMT world, and in those agencies that are trained in glucometry, the indications for blood sugar determination may be limited (such as for patients with altered mental status or decreased level of consciousness). Despite these restraints, it seems reasonable to contemplate blood glucose as a routine procedure. If glucose were to become a fifth vital sign, it would provide opportunities to help identify the 2% of Americans who have undiagnosed type II diabetes. The public health benefit to the communities served by participating EMS agencies would be invaluable, and clearly lives could be saved if strokes or other maladies could be averted through notification, proper medical care and appropriate medication. By the same token, the fire/EMS community would also benefit due to a potential reduction in emergency call volume, reduced exposure to emergency traffic hazards, and the consumption of fewer resources. For more on the SPHERE program, e-mail [email protected]

www.emsresponder.com PUBLIC HEALTH PERSPECTIVES OCTOBER 2008

11

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ADVOCATES FOR HEALTH cont. from page 9 We thank the 3,500 EMTs in King County for their excellent patient care and constant commitment to improvement. We are also grateful to the fire departments and fire chiefs in King County for their support and encouragement of SPHERE. These are: Arlington Fire Department, Chief Jim Rankin; Bellevue Fire Department, Chief Mario Treviño; Black Diamond Fire Department (#17), Chief Greg Smith; Bothell Fire & EMS, Chief Warren Burns; Duvall Fire Department (#45), Chief John Lambert; Eastside Fire & Rescue, Chief Lee Soptich; Enumclaw Fire Department, Chief Jim Zoll; Kent Fire & Life Safety, Chief Jim Schneider; King County Fire District #2, Chief Mike Marrs; King County Fire District #20, Chief Mark Fitzgerald; King County Fire District #27, Chief Chris Connor; King County Fire District #40, Chief Paul Witt; King County Fire District #44, Chief Greg Smith; King County Fire District #47, Chief Mark Tessen; King County Fire District #50, Chief James Knisley; King County Fire District #51, Chief Matt Cowan; Kirkland Fire Department, Chief Jeff Blake; Maple Valley Fire & Life Safety, Chief Tim Lemon; Mercer Island Fire Department, Chief Walt Mauldin; North Highline Fire District, Chief Russ Pritchard; Northshore Fire Department, Chief Bob Peterson; Port of Seattle Fire Department, Chief Mike Mandella; Redmond Fire Department, Chief Tim Fuller; Renton Fire Department, Chief David Daniels; SeaTac Fire Department, Chief Bob Meyer; Seattle Fire Department, Chief Gregory Dean; Shoreline Fire Department, Chief Marcus Kragness; Snoqualmie Fire & Rescue, Deputy Chief Bob Rowe; South King Fire & Rescue, Chief Al Church; Tukwila Fire Department, Chief Nick Olivas; Valley Regional Fire Authority, Chief Mike Gerber; Vashon-Maury Fire & Rescue, Chief Keith Yamane; Woodinville Fire & Life Safety, Chief Dennis Johnson. Mario H. Treviño, MPA, CFOD, is chief of the Bellevue (WA) Fire Department. He has 35 years of experience in the fire service, and has served as chief in San Francisco and Las Vegas. Lindsay White, MPH, is a research assistant in the Medical QI section of King County Emergency Medical Services. She has been working in EMS since 2006. She is particularly interested in out-of-hospital cardiac arrest and the contribution of EMTs to the identification and management of chronic conditions. Hendrika Meischke, PhD, is a professor of health services at the University of Washington and very interested in the role of EMS in addressing public health needs. Mickey S. Eisenberg, MD, PhD, is medical director of King County EMS and professor of medicine at the University of Washington. He has been actively involved in studying and creating innovative programs to improve EMS for over 33 years.

people to the emergency department with hypertensive emergencies and discovered people with new-onset diabetes. In fact, according to satisfaction surveys from over 4,000 people screened, they were extremely happy with the EMS health advocates and the results they received. On a scale of 1–5, with 1 being poor and 5 being excellent, EMS health advocates were rated 4.9+ out of 5 for professionalism and 4.8 for their quality of work. Screening participants are taking action to improve their health. Four fifths said they learned something they didn’t know through the screening process, and only 6% said they didn’t plan to do anything with the information they received. The rest (94%) planned to take action on or otherwise use the information they learned about their health in the screening process.

FLU SHOTS By partnering with the EMS agencies, hospitals and insurers, Emed Health’s health advocates have been able to vaccinate more than 10,000 people in the last year in clinics, hospitals and other sites around the city. Over 6,000 of these doses were administered to the special-needs populations (poor people or disabled people over the age of 65) of health insurers or flu clinics, and 3,800 were administered to nurses, doctors and other clinical staff through a roaming paramedic hospital program. This roaming system was implemented because the hospitals had a vaccination rate of less than 40% among healthcare providers—a number that was even lower for ICU and emergency department staff because they were too busy to leave their units to attend free flu clinics. Medics delivered vaccines to personnel in eight hospitals. The hospitals saw increases in vaccination rates of almost exactly the number of flu vaccines given by the roaming paramedics, meaning the program likely captured people who would not otherwise have been vaccinated. The program was well received by hospital staff, and there are plans to expand it. Studies have shown that vaccinating healthy workers saves employers $42 per person vaccinated, but it probably saves much more in the hospital setting, where nursing shortages are bad, staff work in

12 OCTOBER 2008 PUBLIC HEALTH PERSPECTIVES www.emsresponder.com

close proximity with frequent exposure to the flu, and patients are at risk of contracting the flu from staff.

COMING NEXT The next major initiatives on the horizon for Emed Health are programs for management of congestive heart failure, COPD and diabetes, secondary fall prevention and general chronic disease management, in addition to expansion of the current asthma management program. According to Paris, of the approximately 60 million people in the U.S. who have hypertension, about half are undiagnosed and will develop CHF, strokes and MIs. Finding these people through screenings and educating them before they develop complications makes sense. According to Docimo, insurance companies are interested in working with companies such as Emed to help reduce the billions spent on manageable diseases. “With healthcare costs rising, the focus needs to be on keeping patients well instead of treating them when they’re sick,” she says. “We try to treat their problems before they reach the ED, because it’s obviously a lot more expensive to treat people in the hospital than it is to keep them out of it.” In some states, legislation may be needed to expand EMS providers’ scope of service. Nurses, physicians, insurers and others in the healthcare community need to be educated about the role EMS providers can play in reducing the nearly 120 million ED visits in the U.S. each year. Those who have seen Emed Health’s program are convinced it can work. “I’m optimistic,” says Chris Dell, executive director of suburban Elizabeth Township Area EMS, “that there will be more paramedics and EMTs working with Emed Health and other programs to provide preventative healthcare.” Special thanks to Kelly Close, MD, MPH, Debra Lejeune, MEd, NREMT-P, and Katie Renze from Emed Health for their help. Sascha Liebowitz is a California-based writer. E-mail [email protected] com. Mike Taigman is a lifelong student who works with EMS systems worldwide. Contact him at www.miketaigman.com.

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