Emergency services are a core function of local government. As your County Mayor, it is an issue that I take seriously. This article is going to focus specifically on our Cumberland County Emergency Medical Services (EMS) Department – our local ambulance service. It is lengthy, but that is necessary to give the full picture. Please take the time to read the article in its entirety.
I have been studying our EMS in-depth since taking office as your Mayor in September of 2018. Cumberland County, the fourth largest county geographically in the state of Tennessee, has six EMS stations strategically located across the county in the City of Crossville (Main Station), Fairfield Glade, Tansi, Pleasant Hill, Crab Orchard, and Mayland. Each of these stations has one Advanced Life Support (ALS) ambulance except for the Main Station in Crossville. The Main Station has two ALS ambulances and one Basic Life Support Ambulance (BLS). The BLS ambulance runs 16 hours a day, seven days a week. That gives Cumberland County a total of seven ALS ambulances and one BLS ambulance to serve our needs.
ALS vs BLS Ambulances
There are a few differences between ALS and BLS ambulances. Cumberland County has chosen to equip our BLS ambulance exactly like our ALS ambulances, which means the difference is in personnel. At minimum, an ALS ambulance must be staffed with a Paramedic and an EMT for advanced life support. A BLS ambulance may be staffed with two EMTs.
The two ALS ambulances at the Main Station are staffed with two Paramedics and no EMT. That gives us flexibility to quickly convert a BLS ambulance into an ALS ambulance by moving a Paramedic to the BLS ambulance and an EMT to the ALS ambulance. This is the reason we chose to equip the BLS ambulance the same as our ALS ambulances. It is by design and was done specifically to give flexibility.
In addition to emergency transports, our County EMS transports patients inside the county for various needs. These transports are not for the benefit of the facility, they are for the benefit of the patient. For example, patients that are not ambulatory may need to go from a skilled nursing facility to the hospital or another medical provider for a procedure. Although these are not emergency situations, the county is compensated for these transports and they provide a valuable service to those in need.
Rural hospitals are closing in counties around us. We are blessed in Cumberland County to have a local hospital, Cumberland Medical Center (CMC, a division of Covenant Health), to provide for the healthcare needs in our area. Several rural area EMS Departments without hospitals must transport all patients to a facility outside their county. The Cumberland County EMS Department transports patients from skilled facilities to other hospitals outside the county when local facilities are unable to provide the care needed. Areas that are more urban in nature generally have several hospitals nearby to choose from when transporting a patient. If they have a patient that is a child, or one that has a heart attack or stroke, they can transport directly to the hospital that fits the patient need.
In Cumberland County, a patient may be transported directly to CMC for stabilization or evaluation but require a procedure or specialist that is not available here. Again, these transports are not for the benefit of CMC, they are for the benefit of the patient. These patients need and deserve transportation to a facility that can provide the specialty services they require. The Cumberland County EMS Department provides this vital transportation service for the patient, and we are compensated for it. If I am ever in this situation, I would expect no less. I suspect everyone else would want this service as well. If we eliminated non-emergency transports, we would be reducing income to the EMS Department which could result in a larger subsidy to run the service or reducing the number of ambulances available.
The response time for an ambulance run (or incident) is calculated by using the time the call is dispatched until the time the ambulance arrives on scene. It is important to understand what constitutes response time.
There are several points in time that are captured when a call is received by the Cumberland County Emergency Communications Center when 911 is dialed. The Call Received time is when the call is answered by dispatch. The Dispatch time is the time that the emergency responders (EMS, Fire, Sheriff, etc.) are informed of the need to respond. The Enroute time is the point when the emergency responder is enroute to the scene. The On Scene time is when the responder arrives, and the Call Clear time is when the call is completed.
The time between Call Received and Dispatch varies but can be around two minutes. This time is NOT considered when calculating response times as the responding department has no control over this process. The time between Dispatch and Enroute is called the chute time. This time is considered in the response time calculation as the responding department does have control over it. For example, if an individual dials 911 at 9:00 AM, the Call Received time would be 9:00 AM. If it takes two minutes for the Dispatcher answering the call to get the information and determine who to dispatch and contact that responding department, the Dispatch time would be 9:02 AM. If the call went to EMS and it took one minute to get to the ambulance and head toward the scene, the Enroute time would be 9:03 AM. If the ambulance arrived at the location at 9:12, the On Scene time would be 9:12. In this scenario the response time would be calculated from 9:02 AM until 9:12 AM for a response time of 10 minutes. This is the standard calculation for evaluating response times.
County Technical Assistance Service (CTAS) is an organization created by the state of Tennessee to assist local county governments with the services and resources needed to effectively govern. In addition to my review, on February 29, 2019 I requested CTAS evaluate Cumberland County’s current ambulance utilization and identify areas that may need to be improved. There were other studies from other counties already on the CTAS schedule, and there were personnel changes during the process that delayed the final report until late August. Details of that report are included in this newsletter. Personnel from the Tennessee Department of Health have also reviewed Cumberland County response data in detail.
Improvements to EMS
During the last year, we have made several improvements to the EMS Department. One is the addition of the BLS ambulance mentioned previously. The BLS ambulance can help reduce the need for an ALS ambulance to transport patients from facility to facility inside Cumberland County.
The two stations with the most volume, the Main and Fairfield Glade stations, do not routinely transport patients out of county to other medical facilities. This is because we know, statistically, the next call to 911 for EMS will likely be dispatched from one of these two stations. The addition of the BLS ambulance means that all ALS ambulances are at their station more frequently to respond to calls in their area.
We have also added a paging system to the stations to improve the time it takes for our EMS personnel to get on the road (chute time). As soon as the paging system alerts, personnel can get to their ambulance and start getting location information for the call.
New stretchers were purchased with grant funds and video laryngoscopes were donated for about half of our ambulances with more to be added this year.
GPS devices have been ordered and will be added to our ambulances to help our responders find the location of the emergency quicker.
We are also purchasing software that will help transfer data from the CAD system in the E-911 Department to the EMS software. This will eliminate the possibility of incorrect data entry from the EMS side.
Cumberland County is the only county in the Upper Cumberland to have a ventilator wing in a skilled nursing facility. To help meet the needs of these patients, the State has given the County two ventilators and our Cumberland County Paramedics have all become Vent Certified. We also have our first two Paramedics that have become Critical Care Certified! We are blessed to have employees that take their job seriously and want to provide the best care possible for their patients.
A significant development this year is the First Responder program. This is a program overseen by our Volunteer Fire Department that covers the entire county except for the City of Crossville (they have their own First Responder program via the City Fire Department). The county program serves to get emergency treatment on scene a quickly as possible.
I mentioned earlier that I asked CTAS to evaluate our current ambulance utilization and to identify areas that may need to be improved. The study data included all incidents (runs) in 2018. The entire report can be found on the county website, www.cumberlandcountytn.gov under the Documents page. The following is a summary of some of the findings:
- The largest number of calls originate from the main station downtown.
- The second largest number of calls originate from the Fairfield Glade station.
- Two thirds of incidents in the data were logged between 6 am and 6 pm, with the highest rate occurring between 2 pm and 3 pm.
- Tuesday and Friday were nearly equal as days having the highest number of incidents. The fewest number of incidents occurred on Sundays.
- Incidents were coded with a Priority of 1 to 3, with 1 being the most severe. Over half (51.3%) of the incidents were coded as Priority 3, with 18.7% as Priority 2, and 30% as Priority 1.
- Response times in minute range categories were estimated for all calls and for each priority. For all 11,244 incidents, approximately 59% were on scene in 10 minutes or less, with over one‐fourth (26%) in five minutes or less.
- When only Priority 1 and Priority 2 calls are considered, 65.2% of calls are on scene within 10 minutes. This is across the county, not just in the urban areas consisting of Crossville, Fairfield Glade, and Tansi.
- A heat map of Priority 1 incidents with a dispatch to scene time of 10 minutes or more is presented in Figure 14 of the study. The highest density of these incidents is near the Fairfield Glade station.
- A hot spot analysis of Priority 1 and Priority 2 incidents indicates a hot spot in Fairfield Glade.
- Over all incidents, approximately 23.4 % of calls are overlapping – received during the same hour as another call is received. More of these overlapping incidents occur at the Main Station than any other. If the CMC address is excluded from the count, the next greatest number of overlapping incidents occurs in the Fairfield Glade area.
The following is a quote from the CTAS Study:
Cumberland County has unique challenges to provide ambulance service coverage in a cost‐effective manner. The area’s road network, geographic features, and large areas of rural population do make it difficult to provide a consistent response time to the entire county. The EMS department should continue to rotate/move up trucks to help cover areas vacant due to the assigned ambulance being committed on a response or unavailable. The addition of an ambulance Monday – Friday approximately 0800‐1800‐time span in the Fairfield Glade area should be considered as the funds are available. This can be accomplished by converting the basic life support (BLS) ambulance to an advanced life support (ALS) ambulance and backfilling the Fairfield Glade station while the Fairfield Glade ambulance is on a call. This truck can be used to cover other areas as needed based on system demand.
There are lies, darn lies, and then there are statistics. That is a slightly cleaned up version of the first thing my statistics professor taught me back 30 plus years ago in college. Statistically, how you answer the following questions is important:
- What is the standard definition of response time?
- How do you calculate response time?
- Are calls that have a First Responder on scene first treated differently in the calculation of response time guarantees?
- Are response times calculated and guaranteed based on call priority, such as Priority 1 emergency runs, or all priorities?
At the end of the day, the question we should all be concerned with is how our EMS Department is doing in delivering patient transportation services. Are we perfect, or is the sky falling? As in most cases, the answer is somewhere between the extremes. The County has had our EMS Department and the CAD (run/incident) data reviewed by independent third parties that include the State of Tennessee Department of Health and CTAS. Both reviews have shown strengths and opportunities to improve – as one would expect. Both agencies have also indicated that Cumberland County is doing a good job providing services to our community, and that we should continue to work to improve.
Statistically speaking, we could pull ambulances from the outlying stations and put them in the more populated urban areas of Crossville, Fairfield Glade, and Tansi. That would improve our statistics as most calls come from the urban areas. But we live in the fourth largest county in the state by land mass at 681 square miles. What happens to those calls in the outlying areas? We know that in those urban areas during 2018, 70% of all calls, excluding transports, had a response time of 10 minutes or less. That is regardless of priority. The E-911 Center does not currently do priority dispatching so that data includes calls with everything from twisted ankles to heart attacks. We know from the CTAS data review that priority 1 calls county wide are responded to at a quicker rate than priority 3, which is as it should be.
Financially there are questions as well, such as how often are ambulances rotated out of service for replacement, and are we remounting or purchasing all new ambulances, etc.? Our current EMS operations are at the breakeven point or better operationally, but the county does fund capital costs that exceed the department income. Generally speaking, the county keeps our ambulances newer than some private companies. By resolution, all vehicles shall not be more than 10 years old from the date of new sale or have more than 225,000 miles on the odometer. This means we replace ambulances on a rotating basis almost every year, except for the current budget year. That is because we bought four new ambulances during the last fiscal year so we didn’t need to remove any from service this year. We are also at the most expensive point of the replacement cycle as we are replacing the trucks and “box”. The box is the part of the ambulance that is used for medical procedures and where the Paramedic and patient ride to the care facility. The boxes we are currently purchasing can be remounted two times on a truck chassis. We are in the cycle of buying both the truck and the box. That cycle ends next year and then we will be able to replace the truck and keep using the box, which is a significant savings.
A lot has been said concerning privatization of our EMS Department. The Cumberland County Commission has the final say on how our emergency medical services are delivered, either public or private. On several occasions they have voted via the Emergency Services Committee to keep our EMS Department a part of county government. The most recent vote was in June of 2019, just a few months ago. After studying our EMS Department, talking with counties with public and private services, as well as talking with former employees of private companies, I agree with this assessment. Guarantees of service and delivery from private companies all come with legal caveats, but philosophically should emergency services be privatized? Some government functions may be tailor made to be privatized but should our Fire, Police, and EMS be privatized? I don’t believe they should because when they are, emergencies become a business instead of a service.
As I stated earlier, emergency services are a core function of county government and should be a priority. The next step is to follow the recommendation of the CTAS report to move an ambulance to Fairfield Glade when their ambulance is on a call. We will do this by converting our BLS ambulance to an ALS ambulance. That will leave our outlying ambulances in place while helping to improve the service we are providing. It should be noted that CTAS also recommended redoing the study after the Peavine Road work is completed as construction is likely impacting response times.
I would be remiss in closing this newsletter without thanking our EMS personnel. They work hard to provide care to those in need. We appreciate your service and dedication to the citizens of Cumberland County.
Walking up the courthouse steps to my office, I often reflect on the privilege it is to serve as your Mayor. It is an honor I do not take lightly. I take the issues we have seriously and I will continue to do so.
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Cumberland County Mayor