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Emergency ambulance service systems
The Journal of Emergency Medicine, Vol. 1, pp. 355-356,
EMERGENCY
1984
Printed In the USA
AMBULANCE
In this issue of JEit4 there appears an article entitled “Planning for Emergency Ambulance Service Systems” by Hill, Hill, and Jacobs. The authors address a problem familiar to all managers of prehospital care systems: ambulance location and response time. A computer model for ambulance responses was utilized, and the improvement in ambulance response time reported. There are a number of associated issues, which are briefly alluded to, that bear closer scrutiny. The delivery of prehospital emergency medical services varies widely throughout the country, and factors affecting patient outcome and optimal utilization of resources - eg, ambulance location, tiered response, and level of training of those responding - must be critically evaluated. The location of ambulances and prehospita1 personnel, when not handling a medical assistance call, generally falls into one of two distinct patterns: (1) fixed or stationary bases where the ambulance is parked and personnel may relax or be employed in other duties, eg, fire stations or hospitals, or (2) roving mobile coverage within a geographic district or zone. Each of these locations has its particular advantages and disadvantages; however, the decision to utilize one or the other has frequently not been based on an evaluation of its efficacy in providing the desired service but rather on unrelated aspects of the system. As an example, fixed bases are the rule in those systems where prehospital emergency medical services are based in the municipal fire department. This is, of course, necessary because personnel will usually work 24-hour shifts, and a location for re-
Copyright 0 1984 Pergamon Press Ltd
??
SERVICE SYSTEMS
laxation and sleep is necessary. A warm shelter, however, is a definite advantage for the vehicle, fluids and medications, and personnel. In the mobile or roving system there is obviously an increased cost in terms of gasoline and wear and tear on vehicles. One advantage, however, is that a more fluid response pattern can be maintained in that when one ambulance responds to a call, the remaining ambulances can be shifted in order to provide an even response time throughout the city. In most stationary base systems, this does not occur. What is the optimal response system for the delivery of prehospital emergency medical care? Some might argue that a response time under four minutes by an advanced life-support unit is ideal. Although not proven, this may well be true; however, the cost would be enormous. Most systems instead have a hybrid or tiered system of response that utilizes a larger, less highly trained group (police officers, fire fighters, or other first responders) followed by advanced life-support paramedics upon request or concurrently dispatched (but with longer response). Last comes the question of what comprises the optimal level of training for personnel engaged in prehospital emergency care. Certainly the cost of training everyone to a paramedic level is prohibitive, and perhaps not necessary. It may well be that a basic EMT with certain additional skills, i.e., defibrillation, may provide the optimal answer. Opinions regarding each of these issues vary considerably and will be vehemently defended. The supporting data necessary to
0736-4679/84 355
$3.00
+ .OO
356
identify solutions are sparse. It is time for all of those involved in prehospital delivery of emergency medical services to critically evaluate the needs and to arrive at
The Journal of Emergency Medicine
solutions that are both cost-effective beneficial to the patient as well. Peter Pans,
and
MD
JEA4Section Editor, Prehospitai Care
EMERGENCY
1984
Printed In the USA
AMBULANCE
In this issue of JEit4 there appears an article entitled “Planning for Emergency Ambulance Service Systems” by Hill, Hill, and Jacobs. The authors address a problem familiar to all managers of prehospital care systems: ambulance location and response time. A computer model for ambulance responses was utilized, and the improvement in ambulance response time reported. There are a number of associated issues, which are briefly alluded to, that bear closer scrutiny. The delivery of prehospital emergency medical services varies widely throughout the country, and factors affecting patient outcome and optimal utilization of resources - eg, ambulance location, tiered response, and level of training of those responding - must be critically evaluated. The location of ambulances and prehospita1 personnel, when not handling a medical assistance call, generally falls into one of two distinct patterns: (1) fixed or stationary bases where the ambulance is parked and personnel may relax or be employed in other duties, eg, fire stations or hospitals, or (2) roving mobile coverage within a geographic district or zone. Each of these locations has its particular advantages and disadvantages; however, the decision to utilize one or the other has frequently not been based on an evaluation of its efficacy in providing the desired service but rather on unrelated aspects of the system. As an example, fixed bases are the rule in those systems where prehospital emergency medical services are based in the municipal fire department. This is, of course, necessary because personnel will usually work 24-hour shifts, and a location for re-
Copyright 0 1984 Pergamon Press Ltd
??
SERVICE SYSTEMS
laxation and sleep is necessary. A warm shelter, however, is a definite advantage for the vehicle, fluids and medications, and personnel. In the mobile or roving system there is obviously an increased cost in terms of gasoline and wear and tear on vehicles. One advantage, however, is that a more fluid response pattern can be maintained in that when one ambulance responds to a call, the remaining ambulances can be shifted in order to provide an even response time throughout the city. In most stationary base systems, this does not occur. What is the optimal response system for the delivery of prehospital emergency medical care? Some might argue that a response time under four minutes by an advanced life-support unit is ideal. Although not proven, this may well be true; however, the cost would be enormous. Most systems instead have a hybrid or tiered system of response that utilizes a larger, less highly trained group (police officers, fire fighters, or other first responders) followed by advanced life-support paramedics upon request or concurrently dispatched (but with longer response). Last comes the question of what comprises the optimal level of training for personnel engaged in prehospital emergency care. Certainly the cost of training everyone to a paramedic level is prohibitive, and perhaps not necessary. It may well be that a basic EMT with certain additional skills, i.e., defibrillation, may provide the optimal answer. Opinions regarding each of these issues vary considerably and will be vehemently defended. The supporting data necessary to
0736-4679/84 355
$3.00
+ .OO
356
identify solutions are sparse. It is time for all of those involved in prehospital delivery of emergency medical services to critically evaluate the needs and to arrive at
The Journal of Emergency Medicine
solutions that are both cost-effective beneficial to the patient as well. Peter Pans,
and
MD
JEA4Section Editor, Prehospitai Care