Petersens recipe for smaller, faster, cheaper emergency response
Asking a single ambulance to cover all of El Dorado Hills is “simply not the fastest way to get sick people to hospitals,” said Craig Petersen. He and his wife Sherry are running for the two contested seats on the El Dorado Hills Fire Board.
They question the ratio of 12 fire apparatus to one ambulance, given the high percentage of medical vs. fire calls in El Dorado Hills.
Their campaign website, edhfirefacts.com, contains comparisons to similar fire and emergency medical response agencies that they say demonstrates that the El Dorado Hills Fire District spends more — operations budget, cost per alarm and cost per resident — yet isn’t meeting the industry-accepted response time target: a six-minute response 90 percent of the time.
The Petersens believe that a true six-minute response 90 percent of the time is within reach if the district deploys smaller, more agile, “ambulance-like vehicles,” able to handle steep terrain and narrow streets, dispatched from smaller, less costly, medical-oriented stations situated closer to residential clusters.
The discussion is relevant now because the 2012-13 El Dorado Hills Fire Department capital budget includes a $1.1 million ladder truck, a $600,000 engine and a $4 million renovation of Station 87 on Francisco Boulevard. All told, that’s a $6 million investment in doing things the old way, they say.
The “satellite stations” they’d like to see discussed might be staffed with paramedics who earn, on average, $42,000 per year in the Sacramento area, far less costly than El Dorado Hills firefighters — a fact they know won’t sit well with the firefighters, and especially union leadership.
They insist, however, that these proposals are critical to the district’s ability to meet its commitments to current employees.
Sherry questions the wisdom of sending “slow trucks lumbering up Serrano Parkway or Wilson Boulevard,” as the initial response, with the ambulance typically arriving shortly thereafter. The actual delay is a matter of some debate.
“Even if we don’t have satellites, there are all kinds of options to do this better that we should research,” she said.
Heart attack patients need surgical de-clotting procedures that can only by administered in a hospital environment, said Craig. “So every minute makes a difference, not only to survival but whether you may be permanently disabled.”
Other districts have already shifted their response strategy. The Hanover County Fire Department in Virginia is responsible for 90,000 residents spread out over 500 square miles, and is now meeting response targets with a “Quick Response Vehicle” program that uses SUVs to get to the sick and injured quicker than ambulances or fire engines.
The two-year test results found significant improvements in patient response times without increasing personnel costs, according to the department website.
Hanover’s QVR program and the Petersens’ proposals are both products of the Golden Hour theory and the related “Load and Go” strategy, according to Craig Petersen. Patients who get into surgery within one hour have much higher survivability rates, so agencies are increasingly prioritizing fast arrival, short on-scene times and expedited patient transfer.
El Dorado Hills Fire Chief Dave Roberts defends the district’s emergency medical response strategies and its participation in the county Emergency Services Authority, the Joint Powers Authority that oversees it all, including training, dispatch and cooperative “automatic aid” policies.
Roberts argues that the lone El Dorado Hills ambulance is far from overworked, and is never very far away. Ambulances are also stationed in Cameron Park and Folsom.
“We can’t just put an ambulance at every fire station,” he said recently, noting that over half of the nine ambulances on the west slope are busier than the one in El Dorado Hills. It’s not practical, cost-effective or necessary to add more ambulances of any type, he said.
Roberts adamantly defends the practice of sending firefighting apparatus as initial response vehicles for medical emergencies, with the district ambulance arriving shortly thereafter, as practical and completely adequate. The engines are all equipped with Advanced Life Support medical equipment and staffed by paramedics, he explained, just like an ambulance. The only limitation is that the vehicles can’t transport patients to the hospital.
The initial responders stabilize the patient until the ambulance arrives, a delay not reflected in the monthly response statistics. “The ambulance is less than a minute behind the engine most of the time,” said Roberts.
The Petersens don’t see it that way. Stroke and heart attack victims require little stabilization, said Craig. The primary and immediate need is to get that patient to the hospital. “All those stabilizing things can concur in the ambulance on the way there.”
They worry that the Joint Powers Authority is too concerned with its ambulances paying for themselves. “I don’t think an ambulance has to be a profit center,” said Craig. “I just want good care.”
Sherry cites Granite Bay, with no JPA, two ambulances and paramedic-only stations as a local example of the trend towards faster, medically oriented response, “all on a $6.9 million operation budget.”
The six-minute response target was established by the National Fire Protection Association in 1998. “To me that’s the most important metric,” said Sherry. “We need to get there quickly.”
NFPA Code 1710 states that emergency response agencies should respond within six minutes 90 percent of the time. The 2010 version breaks emergency response down to its elemental components.
Dispatch: 60 seconds
West Slope fire agencies are dispatched from CalFire’s Emergency Command Center in Camino. The phone should be answered within 15 seconds and any necessary transfers, such as CHP to CalFire dispatch, accomplished in another 30 seconds.
If the 911 call was placed from a cell phone, it is routed to a CHP dispatch center. Precious seconds transpire while the call is transferred to Camino. This is why emergency responders are so adamant that everyone program CalFire’s Camino Dispatch into their cell phone, 530-626-4911. Stop reading and do it now.
The clock starts when the ECC operator answers the phone. They get 60 to 90 seconds to collect essential information from the caller and contact the responding agency.
Turnout: 60 – 90 seconds
EMS responders get a minute to rouse, dress, and jump in their vehicle. Fire responders get an extra 20 seconds. The Petersens witnessed the inventive staging strategies used by different agencies to meet the tight turnout time.
Respond: 4 to 8 minutes
That leaves four minutes for the first responder to arrive on scene. The code allows another four to get an Advanced Life Support engine or ambulance there, but all responding apparatus in El Dorado Hills are ALS.
The Monthly Response Time Statistics (link) measure the percentage of calls for the month that respond within six minutes at each station for each month. Through August, the four El Dorado Hills stations met the NFPA goal just four out of 36 times. At seven minutes, the score improves to 17. The stations responded within eight minutes 33 out of 36 times.
The Petersens contend that El Dorado Hills understates overall response times by up to a full minute by starting the clock when the Camino ECC contacts the fire station, rather than when the ECC gets the call.
Code 1710 also assumes that all engine companies will be staffed with four firefighters.
Faster not bigger
The Petersen’s see the $4 million Station 87 rebuild as another oversized — 10,000 square feet — fire station that will rarely be staffed by more than a three-person skeleton crew. “Larger fire stations don’t make faster responses,” said Sherry.
They question why El Dorado Hills needs such a large station, and refer by comparison to San Ramon’s new station — the much higher capacity Station 32 in Alamo, which comes in just under 10,000 square feet and has dorm space for eight firefighters plus another room for three engines and an ambulance, at an estimated cost: of $3.5 million.
Many fire districts, including El Dorado Hills, have concluded that a staggered shift consisting of two consecutive 24-hour days, followed by four full days off, minimizes turnover time and is the most efficient way to run consecutive 24-hour crews.
The firefighters work 48 hours straight. They work out, train, eat and even sleep between calls. Each station has a dormitory, a gym and a kitchen.
The schedule has the unintended consequence that sick days become 24-hour affairs, and are primarily backfilled with overtime. Firefighters are allowed eight sick days each year. Non-shift employees get 17 “regular,” eight-hour sick days.
“It’s too much,” said Sherry. “Corporate America figured out a long time ago that when you offer people 17 days of sick time most of them take it, whether or not they’re sick.”
The Petersens point to Folsom’s fire department and others across the county that have combined sick leave with vacation, reducing the overall number in the process, and propose El Dorado Hills follow suit.
Fire service pensions have become unwieldy and embarrassing in El Dorado Hills, they say, with former chiefs and even captains retiring with six-figure incomes, which are then subject to annual cost of living increases, said Sherry.
“Plus, according to CapPERS, our firefighters retire seven years younger and live just as long as everyone else, so they take way more out of the system,” said Craig.
“It’s been portrayed that we’re totally paid up (for CalPERS), but that’s misleading,” he added. “We’ve paid what they’ve asked for, but that’s not the same as having no liabilities.”
The current unfunded liability for pension and healthcare benefits tops $14 million, said Sherry. “Unless CalPERS’ return on investment improves, that number will increase.”
The little things
Besides the big-ticket items, the capital expenditures and the medical and retirement funds, Sherry also identified smaller items on the budget she feels tell the story: $88,000 for uniforms, when similar-sized agencies spend half that.
Most agencies she reviewed spend $4,000 to $5,000 on small tools. In El Dorado Hills it’s $41,000, down from $65,000 last year.
“At some point the board decided to go into water rescue,” said Craig. Stockton fire vehicles and staff apparently trained El Dorado Hills firefighters for most of a week in Ridgeview Park recently, complete with Zodiac rescue boats.
A state park official told Craig that Placer and El Dorado County Sheriff Departments both have water rescue teams, and there’s also a ranger boat on the lake all the time. “He said they didn’t need any more help.”
He later discovered a $12,000 expenditure for wet suits, “after they assured me it was just in the thinking stage.”
“That kind of spending, over and over, all seemingly good things in and of themselves, but at some point you have to stop,” said Sherry. “You can’t do everything.”
“We can’t assume we’re going to get another housing boom,” she added. “Money’s not going to flow in here like it was 10 years ago.”
Most El Dorado Hills residents like the fire and ambulance service they get, but aren’t aware that local firefighters can earn up to $200,000 per year with overtime.
The Petersens’ comparisons contain overall cost per employee and cost per response statistics. El Dorado Hills consistently leads the pack, with a $208,599 cost per employee and a $6,561 cost per response.
Roberts is quick to criticize the comparisons, noting that many of the agencies listed are fire departments within cities, and that their cost numbers are understated because the cities provide administrative overhead that special districts like El Dorado Hills must pay on their own.
El Dorado Hills also beats out the special districts, but there are some close seconds.
It should also be noted that the comparisons are based on each agency’s total budget, including one-time capital expenditures. El Dorado Hills’ budget includes a $1.1 million truck replacement.
Roberts also notes that several of the “low cost” cities and districts in the comparison are in dire fiscal straits, shedding employees, shuttering stations, implementing fees for services and trying to get assessment taxes passed.
What about the next MOU negotiation? “I don’t’ think it would be out of line to ask the firefighters to make a salary sacrifice,” said Craig. “We are all living with less.”
“We’ve asked people across America to take pay cuts,” said Sherry. “The El Dorado County Fire Chief just took 9 percent cut.”
The current MOU puts the base salary for a five-year veteran firefighter paramedic at $87,156. But education bonuses, out-of-grade pay, uniform allowance, longevity pay and overtime drive annual income up, often more than double the base pay.
“I don’t think it’s unacceptable to ask a very highly paid fire department with expensive benefits to understand that we don’t have the revenue to support this kind of compensation anymore,” said Sherry. “Truckee is hiring; they’re paying between $13.64 and $15.10 an hour for an EMT with firefighting experience.”
Craig softened the message. “That can maybe happen over time with the current employees … by just not giving raises, but I think realistically we have to ask for more contributions for health care and pensions.”
He cites his own experience. The free healthcare for life that UC Davis Medical Center promised him when he was hired now costs more than $500 per month.
“There is a lot of money coming in here,” said Craig. “We believe it affects how the current board looks at things. In other agencies where there is less coming in, they spend less and they find ways to be more efficient. If we had less we could still get the job done.”