| Letter to Plaugher with
EMS STUDY 2002 October 27, 2002
Ed Plaugher, Fire Chief
2100 Clarendon Blvd, Suite 400
Arlington, Va. 22201
Dear Chief Plaugher,
Recently a group of ALS providers, working as an EMS committee
for Local 2800 did an analysis of the problems facing our
EMS system from the prospective of the ALS providers that
are in the field doing the job every day. FF/EMT III Chris
Jackson headed this initiative. Attached are the results.
Sadly, these results are nearly identical to the results of
numerous surveys or studies done in the past. Also attached
is an article from 1986 identifying the lack of structure
(promotional opportunities), high call volume and the lack
of support from Fire Department management as major concerns.
For whatever reason, the Arlington County Fire Department
management has consistently refrained from listening to their
EMS field personnel and gone in other directions, which have
ultimately failed to remedy the problems. I am hopeful that
you and the A.C.F.D. senior staff will finally follow the
lead your EMS personnel are providing you through this inquiry.
The top priority as indicated in this most recent inquiry
is the need to provide structure to our EMS system comparable
to the existing level within Fire Suppression. The APFPA wholeheartedly
endorses the return of several layers of structure in Fire
Suppression which were inappropriately taken away under the
leadership of past County Managers. All indications are that
those positions will return under the pending pay changes.
However, both you and Chief Schwartz continue to oppose providing
similar improvements to EMS. The APFPA shorter workweek proposal
contained within our pay plan package created structure in
EMS comparable to the Fire Suppression system. While you support
our shorter workweek proposal, you are recommending the removal
of the EMS structure component. If Fire Suppression structure
is returned without any similar improvements to the structure
within our EMS system, our ALS personnel will once again perceive
the message is that they are not valued at the same level
as Fire Suppression personnel.
The underlying message in this inquiry is that EMS has to
be made a better place to work so that firefighters want to
work there. The current mentality of requiring personnel to
go to EMS school is a concept that has been tried before and
failed miserably. All indications are that the current requirement
is also failing miserably. Not only are new firefighters not
being allowed adequate time to learn the job of a firefighter
(thereby compromising service delivery on the suppression
side), they are simply tolerating a two year mandatory stop
over in EMS. Obviously, that mind set lends itself towards
compromised EMS service delivery. People become firefighters
because they really want to do the job. You need to create
a system that will create that same desire towards EMS. Mandatory
assignment to EMS is a poor policy that compromises both fire
suppression and EMS service delivery!
The high call volume encountered by our EMS units is another
obstacle to creating a desirable work environment. There is
no reason our medic units should be handling significantly
more calls than all other EMS personnel in the region are.
The A.C.F.D. needs to forward criteria to the County Board
outlining specific statistics which, once reached, would require
the addition of medic units.
Another negative aspect of our EMS system, which has been
identified every time our EMS personnel have been questioned,
is the absence of a requirement to provide two ALS providers
on every ALS unit. Mild improvements have been made in this
area, but there needs to be an absolute policy providing two
ALS providers on every ALS unit. It is particularly alarming
that there has been some mention of coupling an ALS provider
with an EMT-Basic and rotating them together on units. This
is exactly opposite of what the EMS field personnel are telling
you! Hopefully, such a contrary policy will not be adopted.
I am hopeful that the Fire Department leadership team will
take the recommendations of their EMS personnel to heart and
finally set a positive direction for EMS. It is truly sad
that decades have passed and the desires of those workers
have been completely ignored.
Sincerely,
Mike Staples, President
CC: Ron Carlee, County Manger
Jim Schwartz, Assistant Chief of Operations
EMS ISSUES INQUIRY
2002
In joint effort with the Arlington Professional Firefighters
and Paramedics Association (APFPA), Arlington County Fire
Department EMS providers developed this inquiry in an attempt
to help identify problems which undermine the quality of service
we provide to our internal and external customers of EMS.
Our ultimate goal is to convey the perspective of the EMS
provider on numerous issues causing frustration, career dissatisfaction,
and substandard patient care. Unfortunately, most of the frustration
revolves around issues that echo similar inquiries submitted
over the past five years.
Before any change can be realized, the person who has the
power to make the change must be sold on the problem. EMS
providers have been described as "complainers who are
paid to endure the working conditions of being a medic. If
they burn out, they should be reassigned to fire suppression".
This sounds less like a career and more like a stress triathlon.
Instead, maybe Medics are individually voicing true concerns.
Maybe they see the deficit of career elements in EMS versus
Fire, and this is mistaken for complaining. Most of the individuals
who subscribe to this sentiment have never been Medics and
therefore their statements lack empathic value. What cannot
be disputed is the low number of prospective medics (Firefighters)
who are voluntarily applying for EMS positions and plan a
long-term assignment.
EMS has the most customer interaction in the ACFD. Therefore,
the service we provide should represent the ACFD as a premier
service, instead of a collection of burnout medics waiting
to transfer back to Fire services.
To maintain organization the issues have been divided into
six categories:
Resources
Recruitment and Retention
Morale and Burnout
Classification and Compensation
Education and Training
Apparatus, Equipment, and Facilities
It is impractical to create a document that focuses solely
on problems. It must be balanced with possible solutions and
a hopeful expectation of change. The last part of this document
will focus on solutions, which will be organized by priority
of resolution.
This document is a summation of the cumulative opinions expressed
by ACFD EMS providers. I would like to thank everyone who
participated in this inquiry. Although everyone may not agree
on every detail of this document, I believe the majority of
EMS providers feel that the suggested changes would have a
positive impact on EMS in the ACFD.
Resources
EMS Advocacy, Representation, and Leadership
Since the unification of Fire and EMS and subsequent loss
of the Assistant Chief position of EMS, it's apparent that
EMS issues are not receiving appropriate representation at
the highest levels. EMS units have the largest call volume
and longest turn around times of all other units. Technology
and medical standards change on a daily basis. EMS needs an
advocate who understands the nature of what we do and has
the perspective necessary to prevent issues from becoming
overwhelming to personnel.
EMS issues have been conveyed to Administration through
several documents. Most of the issues remain unresolved.
EMS Barriers report -1997
SFA report - 1999
TriData report - 1999
The inherently flat rank structure of EMS leaves a deficit
of leadership at the customer service level. EMS Supervisors
are only dispatched on calls meeting certain criteria. Most
supervisors also monitor the radio and respond to other incidents.
Due to high call volume, it would be impossible for Supervisors
to respond to the majority of calls. Therefore, the quality
of care a patient receives is not guaranteed.
An officer on every medic unit would ensure that the most
qualified individual is in charge of patient care and reduce
the stress of new medics who are placed in charge of patient
care without any experience in EMS. Other advantages include:
Chain of command would have a more laminar flow
Improved identification of medics at burnout threshold
Better accountability of apparatus and equipment
Increased resources for personnel evaluations and
QA/QI
More qualified acting EMS Supervisors
Having an EMS career ladder would improve recruitment
and retention
Better training for ALS Trainees
1:3 supervision ratio is closer to the established
fire suppression ratio than 1:14 for EMS
ALS personnel lack supervisory parity with fire suppression
as shown below. Most Fire Suppression Captains cannot supervise
ALS procedures and the EMS Captain is left to write all of
the performance evaluations with some input from the Suppression
Captain. The following chart represents current budgeted positions.
Suppression EMS
Captains Firefighters Medics BCO____________
Station
#1 1 2 4
#2 1 3 4 2 BCs
#3 1 2 0 2 EMS Captains
#4 2 5 4 3 Captain rovers
#5 2 3 4 1 Fire Marshal
#6 2 4 4
#7 1 4 0
#8 1 4 0
#9 2 3 4
#10 1 2 4 _____________________
14 32 28 2 EMS & 3 Fire
Captains
The data shows that suppression has 14 captains responsible
for 32 Firefighters and 2 EMS Captains responsible for 28
ALS personnel.
Reinstitution of EMS as its own division with budgetary control
and expanded leadership would solve most of the problems associated
with advocacy, representation and leadership.
Two ALS provider minimum staffing on medic units
Frequently, when EMS staffing falls below two medics per unit,
a Firefighter/EMT-B is placed on the medic unit as a driver.
One ALS provider is left to perform multiple tasks that would
normally be shared between two ALS providers. This places
undue stress on both providers who attempt to maintain patient
care standards.
The Virginia Office of Emergency Medical Services regulations
are being met, but these minimums don't necessarily meet the
needs of the ACFD or the expectations of citizens who call
us in crisis. Surrounding jurisdictions with similar departmental
operational standards and demographics as the ACFD have two
ALS provider minimum staffing on their medic units.
Several years ago, In an attempt to eliminate this problem
the ACFD administration provided additional EMS positions
to each medic unit. Due to poor EMS recruitment and retention
most of these positions remain vacant.
Unique problems encountered with this scenario include:
The firefighter driver may not be familiar with the
medic unit they're assigned to drive, its equipment, or driving
routes.
Non supervisory personnel are required to operate
autonomously and also supervise one or more other members.
Firefighters are often unhappy when detailed to medic
units and sometimes are unwilling to perform the duties necessary
to ready the unit for service after calls.
Medic teams are being split to provide staffing to
a Paramedic enhanced fire suppression unit. Paramedic Engine
companies will eventually enhance the ALS service in the ACFD,
but this should be secondary to providing each medic unit
with two ALS providers.
Current minimum ALS staffing requirements are counterproductive
for both the internal and external customers of the ACFD.
It asks too much from a single ALS provider, contributes to
substandard patient care, and exacerbates medic burnout.
Two ALS provider minimum staffing is essential for improving
recruitment, retention, morale, and standards of patient care.
Inadequate number of EMS units
Having the ability to respond to the needs of the citizens
is the highest priority of the ACFD. However, Arlington County
runs out of EMS units on a constant basis. Two daytime (12-hour)
medic units were approved to upgrade to day/night (24 hour)
service. Medic 101 upgraded to 24 hours in June/02 and Medic
110 will upgrade in January/03. This was only accomplished
though efforts of the APFPA and Arlington County Board. This
change has had little impact on the number of times the ACFD
runs out of EMS units. Plans to place additional units in
service have met resistance from ACFD management. The only
response to the lapses of coverage was to create an announcement
from ECC identifying that Arlington has zero medic units available.
The 1999 SFA report used statistics and graphs to justify
the placement of additional EMS units in service. Findings
justified 8 full time ALS units and recommended a process
that regularly reevaluates the need for additional units to
prevent future shortages and subsequent consequences. This
will prevent future conditions that contribute to ALS provider
burnout.
How many times has ECC announced that Arlington has zero fire
suppression units available?
EMS Medical Director issues
The EMS Medical Directors perform an essential role in Arlington
EMS and should be paid for this position. It is unreasonable
to ask for this level of commitment and responsibility without
compensation.
The EMS Medical director should be the Arlington representative
on the EMS council in order to ensure accurate information
exchange and appropriate needs recognition for our system.
Fire Captains dropping ALS certifications
Fire Officers in the ACFD are finding it impractical to retain
ALS certification after promotion. There are not enough incentives
to justify the additional work required to maintain their
certifications.
Fire officers with ALS certifications rarely place their fire
suppression units in service as ALS qualified. This contributes
to stagnation of their skills and a loss of interest in ALS
care.
Changing the premium pay for EMS to level one for Intermediate
ALS certification and level two for Paramedic ALS certification
would provide Fire Officers extra incentives to maintain ALS
certifications. This would also help bridge the compensation
inequity between intermediate and paramedic ALS providers
(see Compensation).
Recruitment and Retention
Recruitment and retention problems in EMS are caused by an
accumulation of the neglected issues prospective recruits
(Firefighters) see everyday. The lack of an internal career
ladder, negative EMS sentiment, and heavy workload deter the
majority of personnel from entering an EMS career. Others
are lured by the promotional advantages that riding in charge
of an EMS unit provides. Citing recent promotions, ALS providers
seem to be the best candidates for the Fire Captain positions.
Although this is good for the individual, it creates retention
problems and robs leadership from EMS that would be retained
if there were more EMS promotional opportunities available.
Recruitment practices for new Firefighters had to be changed
to make up for the low numbers of experienced firefighters
applying for EMS positions. New Firefighters are required
as a condition of employment to obtain ALS certification and
are transferred to EMS for two years. Many of these people
have stated that they don't want to be in EMS and will only
do the minimum or feel intimidated by the level of responsibility
cast upon them.
Obviously this is not the best solution to recruitment problems,
but it seems to have become necessary for a short-term fix.
The long-term fix can only be centered on making EMS a better
place to work.
Morale and Burnout
The current feeling among ALS providers is that no one understands
the working conditions many providers encounter on a daily
basis.
ALS providers spend more time on calls than other
providers in the region do.
ALS providers are required to endure the same 56-hour
week as Firefighters without the normal amount of sleep firefighters
tend to receive.
ALS calls demand more work on a more frequent basis
(few false alarms).
The charge medic does more paperwork than other personnel
do.
The charge medic makes officer level decisions everyday.
ALS providers must meet more initial and yearly educational
requirements than other personnel do.
The charge medic frequently supervises a Firefighter
driver.
Many ALS providers are made to feel dissociated from
the team for being assigned to EMS.
ALS personnel are additionally required to maintain
the same skills, training and station duties as a basic Firefighter.
Working the long 56-hour/wk shift seems to have the biggest
impact on burnout for ALS providers. ALS personnel are required
to maintain skills for two separate careers and are required
to work an additional 14 hours per week, for less compensation
than other local jurisdictions. Obviously, stress saturation
levels are different for each individual depending on background
and exposure. ALS personnel report reduced stress when utilizing
leave after a demanding shift and would prefer fewer hours
per week to a pay increase.
These multiple demands place an unreasonable amount of stress
on ALS providers, who are usually the last to realize when
they have exceeded their burnout threshold. Currently there
is not a standard for how burnout ALS providers are handled.
Some have been given a temporary reassignment to firefighter
duties and some have received disciplinary action. The difference
in the two courses of action depended on the recognition of
signs and symptoms being associated with burnout, or the behavior
having been interpreted as a disciplinary problem. Creating
a plan to identify and assist burnout ALS providers will assure
equitable treatment of providers who are near or past their
burnout threshold and prevent future witch-hunts.
Morale among ALS providers is in need of serious repair. Provider
morale has deteriorated from prolonged neglect of items identified
in numerous reports over the past five years. Showing that
EMS is a priority with a commitment to work out identified
problems will reduce the factors creating morale problems
and burnout in ALS providers.
Classification and Compensation
Inequity in classification and compensation in EMS as compared
to the rest of the ACFD and surrounding jurisdictions presents
a significant barrier to recruitment, retention, and career
satisfaction.
Classification issues, ALS Unit Responsibility
Imagine a new trainee Firefighter being given Fire Officer
responsibilities his first day on the job and he is also told
that he will permanently rotate in charge, interchangeably
with the Fire Captain. He and the Fire Captain have been trained
in an ACFD recruit school, so their education level makes
them equally qualified for the position. Also, the new recruit
will make only $1266.00 less than the Fire Captain will. The
new Firefighter is overwhelmed and the Fire Captain's morale
is depreciated.
Even though this seems like a ridiculous scenario, it emphatically
demonstrates the perspective of new ALS recruits and veteran
ALS personnel. The impact of this scenario reaches deep into
problems with recruitment; retention, morale, and burnout.
Trainee ALS providers are being trained and certified to the
EMT-Intermediate level. The Paramedic having one additional
year of education than the EMT-I is recognized by the VAOEMS
as being ultimately responsible for patient care when working
with an EMT-I. The ACFD provides no rank distinction and only
minimal compensation for the additional education and responsibility.
Giving equal responsibility to two groups of ALS providers
whose qualification levels are significantly separated by
increased experience, education, and exposure is inequitable
and lacks parity when compared to fire operations. Having
Paramedic certification should be a prerequisite to the recommended
medic unit supervisor position. Expanded leadership at the
medic unit level would give patient care responsibility to
the most qualified provider ensuring that the highest standards
of patient care would be met.
ALS units are the only apparatus that rolls out of the firehouse
without someone in charge.
Classification, EMS Supervisor Promotions
EMS Supervisors are being promoted based on scores received
on the Fire Captains assessment center. This does not adequately
assess for ALS provider performance or the knowledge of the
duties of an EMS Supervisor.
EMS Supervisors perform extraordinary tasks including RSI,
which is a quick method of anesthesia, to gain control of
an airway in near death patients. Neglecting to assess for
refined ALS abilities could have devastating consequences
when difficult skills or patient care decisions are required.
EMS Supervisors should have a separate promotional process
to adequately assess for abilities related to the position.
This will help ensure the highest quality of leadership in
EMS.
Compensation, Regional pay comparisons FY 02
Competitive pay is necessary to enhance recruitment and retention
for EMS. The FY 2002 APFPA pay comparison for paramedics found
Arlington Paramedics to be behind all other departments included
in the study. The departments used for comparison each had
individual compensation advantages such as a shorter workweek
(Alexandria) and promotional opportunities at the Paramedic
level (Fairfax co). This combination places ALS providers
significantly behind their regional counterparts.
Arlington Alexandria Fairfax co
Base pay 14.74 - 23.76 16.73 - 27.77 15.60 - 24.95
Per hr.
% Lowest rate + 13 - 18 % + 6 - 6%
Other None * 42 hr. week vs. ** Promotional
56 hr. week opportunities
could increase
pay 10%
* Alexandria ALS personnel have a 42 hour work week v. Arlington
with a 56 hour workweek. This benefit was factored into the
hourly base pay rate, but the morale impact and stress reduction
benefits are advantages to the employer and employee that
remain immeasurable.
** Recognizing the demands placed on the ALS provider in charge,
Fairfax co. has an Officer on each ALS unit. The associated
pay increase could be up to 10% for the ALS provider.
Giving consideration to all compensation benefits, an Arlington
ALS provider is initially behind the compared groups 6 - 13%
and 16 - 18% at their retirement.
Compensation, Pay plan problems
Current practices of moving employees through the pay plan
leave employees with the same hire date at different steps
when comparable departmental advancement changes their pay
grade. Pay plan movements should be calculated to get the
same result for employees moving to the same grade who have
the same hire date.
Example;
Employee position with x years = y grade at z step
The current county pay plan makes it difficult for public
safety employees to reach top pay. Other Arlington county
employees are hired in a certain pay grade and frequently
retire in the same grade making it easy to reach top pay.
Public safety employees tend to have more frequent internal
movements in grade. This causes the employee to be lower in
step the more they are advanced in grade making it difficult
to reach top pay.
The county should look at a separate pay scale for public
safety employees to reduce confusion in grade movements and
maintain regional pay comparability.
Compensation, Recent Firefighter pay increases
Recently Firefighter level employees were given mid fiscal
year increases to maintain starting pay comparability to other
departments. All Firefighter level employees received step
increases except ALS personnel. Firefighter level employees
also received grade increases except Paramedic ALS providers.
Instead of comparable grade and step changes other Firefighters
received, ALS EMT-Intermediate Firefighters were given a grade
change and Paramedics only received a $1266 per year tech
pay. ACFD Officers did not receive any pay increase.
Many ALS personnel found that they could return to Firefighter
positions at comparable pay some with a pay increase adding
Hazmat and Tech Rescue incentives. This has exacerbated the
previously stated morale, recruitment, and retention problems
in EMS. Appropriate pay adjustments must be made to make this
equitable for all employees.
Compensation, Specialist and Tech pay
The recent tech pay incentive given to Paramedics during the
mid fiscal year increase was not applied the same as Hazmat
and Tech Rescue certification incentives. In Hazmat and Tech
rescue the highest level of certification receives specialist
pay and the lesser certification receives tech pay. Paramedics
with the highest ALS certification received Tech pay and the
EMT- I didn't receive any certification pay.
To maintain parity with certification pay within the ACFD,
incentive pay should be applied equitably. This will also
give Fire Captains with ALS certification more incentive to
maintain and utilize their certifications.
Education and Training
Introduction of the EMT - Intermediate (EMT - I)
Recently, Virginia adopted the new National Registry standard
for EMTs, Intermediates, and Paramedics. This change increased
the educational requirements for all providers. The majority
of ALS providers in the ACFD prior to this change were at
Paramedic level certification. The ACFD has elected to make
the EMT - I the new standard of ALS care rather than meet
the new demands of the new Paramedic curriculum.
The new Paramedic and Intermediate programs are actually two
independent programs without a bridge from one program to
another. This makes it difficult for an intermediate to upgrade
to a Paramedic. George Washington University is currently
running a pilot program for the upgrade.
The following is brief compare and contrast of the old and
new certifications.
New EMT - I v. Old Paramedic The new Intermediate curriculum
is similar to but not as comprehensive as the old Paramedic
curriculum. The new Intermediate curriculum lasts one semester,
215 hours didactic and 120 laboratory instruction with clinical
and field competencies. The old Paramedic had more depth and
breadth of education than the new Intermediates.
In the new Intermediate there is:
Less anatomy and physiology
Less pharmacology - only 12 medications
Less pathophysiology
Less practical skills and scenario training
No medication drips*
No 12 lead cardiology*
No surgical or needle cricothyrotomy*
* The GWU ALS training program may sometimes teach these
skills in addition to basic Intermediate requirements, but
these skills are not part of the Intermediate curriculum.
Old Paramedic v. New Paramedic The new curriculum for the
Paramedic has more depth and breadth of education than the
old curriculum. The new curriculum adds critical care knowledge
such as blood chemistry and more information on disease processes.
The new educational requirements are intended to upgrade the
old street Paramedic to a Critical Care Paramedic.
In the new Paramedic curriculum there is:
More pathophysiology
More pharmacology
More anatomy and physiology
Therapeutic communication
Ethics
Life span development
Well being and illness prevention
The new Paramedic program is a two year program: four semesters
or at least fifteen months, comprising 1,022 hours of instruction
with clinical and field competencies.
Intermediates are trained to know what to do, but may not
completely understand the reasons for their actions. Intermediates
would work well as a part of a Paramedic/Intermediate team,
but shouldn't have the full responsibility of patient care.
Whether in a primary care setting or on the street, ALS providers
need to have more education than ever before. They are required
to perform skills that when performed in a hospital setting
requires the practitioner to have 6 - 8 years of education.
Education of ALS providers needs to be increased to match
increasing demands of the service we provide.
EMS practical skills and scenario training
EMS practical skills and scenario training is essential for
ALS providers to learn and maintain the requirements of their
job. Currently there are no sites available to readily fit
this training into their demanding schedule. Trainee ALS personnel
don't have the ability to practice skills required to pass
ALS competency tests.
Creating two training sites (north and south), to facilitate
skills and scenario training would help providers maintain
high standards of care and increase the competence of trainee
ALS personnel.
Apparatus, Equipment, and Facilities
EMS patient care documentation
When done properly, patient care documentation can sometimes
take longer than the call. The information boxes required
for the VOEMS records makes reports arduous and redundant.
Electronic computer documentation of EMS reports would eliminate
much of the work associated with paper documentation.
Several years ago a pilot program was done for a pen based
electronic reporting system. The system failed to meet the
needs of the providers for the following reasons.
The system could not interact with CAD or RMS. Medics
had to type in addresses, times, and call numbers.
Software problems frequently caused the system to
be out of service
Printing a report relied on hospital printers to
be operational and not in use.
Downloading reports to the main database took to
long and was frequently out of service.
Reports took longer than paper, even with proficiency.
These issues must be resolved for any other system to be
successful.
Apparatus, equipment and facilities had the fewest problems
identified in the survey.
Prioritized Summary of EMS Issues
1. Reinstitution of EMS as its own division with budgetary
control and expanded leadership to include an Assistant Chief
of EMS and Paramedic supervisors for each medic unit.
2. Two ALS provider minimum staffing on ALS units.
3. Employ a plan to place additional EMS units in service
to achieve 8 full time units. Create a process to regularly
reevaluate the need for additional units.
4. Fix compensation issues
5. Develop a plan to identify and assist burnout providers
that doesn't require the provider to lose ALS incentives.
6. Create a separate EMS promotional assessment center or
give a separate tactical test for higher qualified EMS Officers.
7. Build practical skills and scenario training sites.
8. Computer based patient care documentation.
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