The Fire-Rescue Department’s Emergency Medical Dispatch: A Change to the Dispatch Procedure Can Reduce Response Time Knighton Award Presentation to ALGA May 5, 2013

Introduction This audit is important because: It has the potential to save lives. The issues we encountered are relevant to many other audits: Processes have not been streamlined or reexamined for a long time Shortcomings in reporting result in poor information for management decision-making We conducted this audit because: The Fire-Rescue Department is one of the largest departments in the city The majority of emergency calls it receives are for medical aid Even a small efficiency improvement could have a significant impact We had previously conducted an audit of Emergency Medical Services (EMS) but were unable to delve into dispatch operations

Audit Objectives Determine the efficiency and effectiveness of the receipt and handling of calls and dispatching of response units. Assess the adequacy and completeness of dispatch performance reporting to the City Administration and the City Council.

Audit Team Eduardo Luna, City Auditor Chris Constantin, Assistant City Auditor Toufic Tabshouri, Performance Auditor John Teevan, Performance Auditor Martin Wilson, Performance Auditor This was a straightforward audit However, it was data-intensive, presenting the usual problems: Extracting the data Understanding the data Assessing the reliability of the data Dispatch systems are not designed for reporting

EMS Delivery in San Diego San Diego uses two channels to deliver EMS: A vendor, Rural/Metro, operates ambulances

EMS Delivery in San Diego San Diego uses two channels to deliver EMS: The Fire-Rescue Department operates other rescue units

EMS Delivery in San Diego The city is legally obligated to provide two paramedics to serious medical emergencies (Priority 1) An ambulance is typically staffed by one Emergency Medical Technician (EMT) and one paramedic A Fire-Rescue unit is typically crewed by four people, all of whom are EMTs and at least one of whom is a paramedic

Level of Activity In fiscal year 2011, the FCC processed over 118,000 incidents in the city Note: There are often multiple calls associated with each incident. These incidents resulted in more than 97,00o dispatches, 83,000 of which were for medical emergencies Approximately 82 percent of medical calls result in the dispatch of a Fire-Rescue unit

Medical Dispatch Process Overview Emergency calls (911) are received by Police Dispatch Police Dispatch routes fire or medical emergency calls to the Fire Communication Center (FCC) The FCC assigns an ambulance to all medical calls as soon as an incident address is obtained An FCC call taker asks a series of questions to determine the severity of the medical incident The FCC assigns a Fire-Rescue unit to high priority calls, providing a second paramedic

Response Time Measurement Response time is divided into three segments: Dispatch Time, Turnout Time, and Travel Time To account for variance, response time is reported as percentage of calls falling within a period of time For example, Travel Time for 90 percent of dispatches was met within seven minutes

Performance Standards The Fire-Rescue Department was struggling to meet National Fire Protection Agency (NFPA) response time standards. The City hired a consultant to study its response time performance, and subsequently adopted its own standards The Fire-Rescue Department still struggled to meet the City’s adopted standards

Response Time Standards City vs. NFPA Response Time Standards Time Interval City Standard NFPA Standard Dispatch Time: Starts at the phone pickup and ends when emergency units are notified of the incident. 1 minute Turnout Time: The interval between notification and departure to the scene of an incident. 30 seconds 20 seconds Travel Time: Begins when the unit departs to the scene and ends when it arrives at the scene. 5 minutes 4 minutes Overall Time: Total of the above. Time from phone pickup to arrival on scene. 7 minutes 6 minutes

City Response Time Performance Time Interval City Standard Percentage of Dispatches Meeting Standard Time Within Which 90% of Calls Were Met Dispatch Time: Starts at the phone pickup and ends when emergency units are notified of the incident. 1 minute 12% 3 minutes 1 second Turnout Time: The interval between notification and departure to the scene of an incident. 30 seconds 90% 28 seconds Travel Time: Begins when the unit departs to the scene and ends when it arrives at the scene. 5 minutes 76% 6 minutes 13 seconds Overall Time: Time from phone pickup to arrival on scene. 7 minutes 69% 9 minutes 27 seconds

Improving Performance (1) There are two ways to improve response times: Provide more resources Build additional fire stations Hire more firefighters Contract for more ambulances Upgrade dispatch systems

Improving Performance (2) Examine current practices We diagramed the entire process from the time that someone places an emergency call to the time a Fire-Rescue unit arrives on scene We compared the difference between the way that Rural/Metro ambulances and Fire-Rescue units were being dispatched We calculated response performance for the three segments of the process

Response Process

Finding 1 Changes to Fire-Rescue Dispatch Procedures Can Reduce Response Time by up to One Minute

Recommendation 1 We presented two options to the Fire-Rescue Department Assigning and deploying Fire-Rescue units to all emergency medical calls when an ambulance is assigned Implementing a pre-notification and deployment order process for Fire-Rescue units We recommended option 2: The Fire-Rescue Department should implement the pre-notification and deployment order option (option two) to reduce the overall response time for medical calls

Projected Results Measure City Standard Percentage of Dispatches Meeting the Standard Time Within Which 90% of San Diego Calls Would Be Met Dispatch Time: Time from Pickup to First-Responder Unit Assigned Current Performance 1 minute 12% 3 minutes 1 second Projected Performance 59% 1 minute 44 seconds  Overall Time: Time from Phone Pickup to Arrival On Scene 7 minutes 30 seconds 69% 9 minutes 27 seconds 82% 8 minutes 22 seconds 

Finding 2 Fire-Rescue Can Improve the Measurement and Reporting of Emergency Response Times

Finding 2 We discussed ways for improving reporting by measuring: The percentage of emergency calls processed within one minute The percentage of emergency calls processed within one and a half minutes for a first-responder Turnout time The total response time from phone pickup to the arrival on scene time

Recommendation 2 The Fire-Rescue Department should strengthen its monthly measurement and reporting of dispatch data, analyze data to identify trends, and utilize the results of the analysis to identify opportunities to streamline and improve overall performance

Department Response The Fire-Rescue Department agreed with both recommendations The Department chose to implement option 1 and will assign and deploy Fire-Rescue units to emergency medical calls when an ambulance is assigned

Gauging the Audit’s Impact For medical incidents involving traumatic injuries or bleeding, the audit may save someone’s life. For heart attacks, a rapid response increases the chance of survival by 10%-20% per minute within the first few minutes. Achieving these results would have otherwise cost San Diego millions for building new fire stations and hiring new personnel. What is a person’s life worth? Our work is ultimately about serving our residents.

Questions / Contact Questions? For more information, contact: Eduardo Luna, San Diego City Auditor EduardoL@sandiego.gov Toufic Tabshouri, Senior Performance Auditor ttabshouri@sandiego.gov