Since 1838, the Houston Fire Department has provided high quality fire service to its citizens. In 1971 the Houston Fire Department began providing the citizens of Houston with quality emergency medical care. High quality emergency medical care is not defined solely in terms of life saving interventions for critically ill or injured patients. High quality emergency medical care is defined by the decisions made on each and every patient encounter. The challenge EMS providers face is to make important, sometimes critical decisions with a limited amount of information. Other times Houston Fire Department personnel are called upon solely for their opinion as EMS professionals.
The highly educated EMS personnel of the Houston Fire Department pursue excellence in their profession by combining the benefits of medical science with the art of compassionate care. In all cases, potential patients are approached with the greatest professionalism and concern for their well being. In the pages that follow, you will find summaries of facts concerning the Emergency Medical Service system of the Houston Fire Department. We anticipate that after review of the information, a better understanding of the significance and capabilities of the Emergency Medical Service system will be acquired.
Overview and Demographics
�The City of Houston is an amoeboid, six-hundred plus square mile area spread out over a 1000 square mile triangular region in Southeast Texas. It has a night-time population of nearly two million people and over three million daytime population. One out of every ten citizens utilizes EMS. Each year there are over 150,000 EMS incidents involving over 175,000 patients or potential patients. On the average, EMS responds to someone every 3 minutes. Each EMS response is made by one of 60 City of Houston EMS transport vehicles (ambulances), 34 which are staffed by two paramedics, Advanced Life Support (ALS). Of these 34 units, nine function in a "Dual" capacity as both ALS or BLS. Another 26, Basic Life Support (BLS), units are staffed by two EMTS.
Personnel Staffing
The EMS program is integrated into and administered through the over 3000 member Houston Fire Department (HFD). As a result, all EMS personnel are also fire fighters experienced in emergency rescue, extrication, and the suppression and confinement of hazardous materials. All fire fighters are specifically trained and annually re-trained in basic first responder (FR) activities. All new cadets in the fire department since 1981 have also been EMT trained.
There are over 1,700 state certified EMTs available to staff the 26 BLS units. This is an adequate supply of EMTs to meet current and projected needs for BLS staffing. Furthermore, the future supply of EMTs is ensured by the departmental requirement that all new cadets hired receive EMT training
There are approximately 268 paramedics currently assigned to ALS units. This figure does not include EMS supervisors or "Base Station " personnel. The department's goal is to staff two paramedics on all ALS units and maintain a sufficient reserve pool to accommodate staffing and training requirements.
One step to achieve this goal began in April 1996. During fiscal years 97 & 98, three Fire Training Academy Cadet classes were trained as paramedics upon completion of their fire suppression training. The positive impact of this training was felt departmentally in March 1999.
Ambulance Placement
To properly serve the city, ambulance units must be located in a manner that best services all the residents of the city. The location of ambulances is based on the concept of fractal, rather than average response times. Measuring the response time of all sectors of the city derives the fractal response time. Our goal is to have a first responder or BLS on-scene in less than four minutes and an ALS on-scene in less than eight minutes on 90% of all calls.
To ensure quality care to all sections of the city, each unit is located where it can respond predominantly in its defined territory and can arrive at an emergency within the fractal time frames established by the system based on an area's need for emergency service. One territory may have three units to serve its high call volume and another territory may have one unit to serve its low call volume. Both territories, however, have the same response time goals.
The Demand for Emergency Medical Service
The public's demand for emergency medical services has steadily increased over the last nine years from 137,561 EMS incidents in FY91 to 182,222 in FY99. This demand can be defined by the following workload measures.
FY91 FY92 FY93 FY94 FY95 FY96 FY97 FY98
EMS Incidents 137,561 138,735 145,733 150,611 156,525 157,606 166,045 175,485
EMS
Transports 77,345 85,779 93,162 94,487 98,817 99,483 103,670 115,108
Incidents represent the demand for emergency services by the public, while transports represent the resources deployed to satisfy the public's demand for emergency services. To aid with its growing demand for service the Houston Fire Department has enhanced its medical priority dispatch system and has implemented the First Responder program.
Medical Priority Dispatch
Emergency medical dispatchers (EMD), with computer assistance, are able to query callers and determine the appropriate resources to be dispatched. EMDs are able to provide dispatch life support via pre-arrival instructions for appropriate patients. The medical priority dispatch system categorizes and prioritizes requests for emergency medical services based on an evaluation of the life-threatening nature of the request and then relays that information to the First Responders, BLS and ALS units.
First Responder
When the response time for an ambulance unit is delayed, or when a probable critical situation exists, nearby engine or ladder trucks are dispatched simultaneously to initiate BLS as needed or to provide BLS support for the ambulance crew. The First Responder responds to certain emergency types where there is a low probability that a patient transport will occur. Under these circumstances the First Responder is dispatched to a call in lieu of an ambulance unit, saving the ambulance for another, possibly more emergent call. Due to the new expanded patient care role, it has become even more important that engine and ladder companies be consistently staffed with a minimum of four fire fighters. Currently, the department operates 116 First Responder apparatus.
EMS Performance Measures
To help track the quality and effectiveness of the emergency medical service system the department monitors the survival rates of cardiac arrest of its patients transported via HFD. Response times are often misused or misinterpreted as they are only a crude measure of the system. Clinical outcomes such as cardiac arrest survival rates are a more accurate indicator of performance. The importance of response time for first responder units is demonstrated in HFD data that directly correlates response time to cardiac arrest survival as shown in the table below.
Time to First Responder Arrival - % ROSC (Return of Spontaneous Circulation) - % Admitted to Hospital - % Discharged Alive From Hospital
< 5 min. - 52/142 - 36% - 49/142 - 31% - 19/142 - 13%
>= 5, <10 min. - 150/557 - 27% - 183/557 - 33% - 46/557 - 8%
>= 10, < 15 min. - 20/71 - 28% - 16/71 - 23% - 4/71 - 6%
Cardiac Arrest Outcomes: Stratified by Inc. Time-FR Arrival Time Jan - June 1997
Although the overall cardiac arrest survival rate is often referred to as a quality indicator, EMS professionals use witnessed Ventricular Fibrillation (VF) survival rates as a standard.
Currently, HFD EMS is developing a continuous comprehensive evaluation program, which will assess all aspects of the EMS system. This program will include evaluation of structural, process and outcome measures. In addition to survival, other outcomes such as disease, disability, discomfort, dissatisfaction, and destitution could be utilized for evaluation. This enables appreciation of the complete spectrum of EMS effects for the community.
Administration
The EMS Medical Director is responsible for all medical aspects of prehospital patient care. The Medical Director has the authority to approve the level of prehospital care which may be rendered by each of the departments members, establish and monitor compliance with field performance guidelines and establish and monitor training standards. A staff of four physicians provides on-line and/or on-scene medical direction for all critical patients 24 hours per day. Seven EMS nurse assist in the development and revision of protocols, medical standing orders, continuing education programs and addressing equipment and legislative issues.
An Assistant Chief heads the EMS administrative staff with the direct assistance of the District Chief for EMS. These two individuals in essence are the executive classified arm of EMS operations. They are responsible for the implementation of the operational structure- EMS staffing assignments; disciplinary action; complaint disposition; fiscal management; EMS supply operations and compliance with all bulletins, orders, policy and procedures. An administrative support staff of approximately 30 people executes these functions.