evaluating changes in fireifhgter/paramedic staffing

Firefighter/Paramedic Staffing 1

Evaluating Changes In Firefighter/Paramedic Staffing

Executive Development

BY: Bruce Sellon Lincoln Fire & Rescue

Lincoln, Nebraska

An applied research project submitted to the National Fire Academy as part of the Executive Fire Officer Program

November 2004

Appendix D Not Included. Please visit the Learning Resource Center on the Web at http://www.lrc.dhs.gov/ to learn how to obtain this report in its entirety through Interlibrary Loan.


Abstract

Lincoln Fire & Rescue (LFR) provides Basic Life Support (BLS) and Advanced Life

Support (ALS) out-of-hospital emergency medical care and transportation to citizens in

Lincoln, NE. The department was required to evaluate a different firefighter/paramedic

staffing model than what was currently provided. The research problem is; no evaluation

criterion exists to determine the overall impact of different staffing models to the citizens

and LFR. An evaluative research method was used to gather information to determine the

existence of local or national standards for firefighter/paramedic staffing, what criteria

departments of similar size used and what were the similarities and differences between the

current and proposed LFR firefighter/paramedic staffing models. Research and

questionnaires were used to find several staffing models for comparison.

Recommendations to the LFR system included following recommended standards,

pursuing EMS accreditation and considering a rotation system to reduce the stress and

workload for ALS firefighter/paramedics.


Table of Contents

Abstract ............................................................................................................................. 1

Table of Contents.............................................................................................................. 3

Introduction....................................................................................................................... 4

Background and Significance ........................................................................................... 5

Literature Review..............................................................................................................10

Procedures.........................................................................................................................18

Results...............................................................................................................................21

Discussion.........................................................................................................................28

Recommendations.............................................................................................................34

Reference List ...................................................................................................................36

Appendices

Appendix A: (Definition of Terms and Acronyms).........................................................39

Appendix B: (Medic Staffing Questionnaire)..................................................................41

Appendix C: (Fire Departments or Agencies Participating in

First and Second Questionnaire)...................................................44

Appendix D: (Lincoln Fire & Rescue Medic Rotation Survey - Sample Questions)......45


Introduction

Lincoln Fire & Rescue (LFR) provides fire prevention, life safety and emergency

services for the citizens of Lincoln, NE. The department is an accredited agency through

the Commission of Fire Accreditation International (CFAI) since 1997 and was re-

accredited again in 2002. The City of Lincoln covers an area of approximately 79.55

square miles with a 2003 population of 235,594. LFR operates 14 fire stations with a

uniformed staff of 266 and an administrative support staff of 31. Pre-hospital emergency

medical care has been a major service provided by LFR for over 30 years and has taken on

various response configurations. Initially, firefighters trained as Emergency Medical

Technicians (EMT’s) responded with fire suppression engine companies to medical

emergencies and provided Basic Life Support (BLS) medical care. Need for emergency

services increased in both volume and care level, therefore a response change was

necessary. Advances in pre-hospital emergent care led to LFR providing EMT-Defibrillator

trained firefighters and a hospital-based team of critical care nursing staff to respond to all

critical Advanced Life Support (ALS) calls (LFR, 2004).

In spring 1994, LFR had a goal to provide the best medical care possible to each

patient’s side. Training began to staff each engine company with a firefighter trained to the

EMT-Paramedic (EMT-P) level. Medical transportation to hospitals was provided by a

private, for-profit agency until 2001 when LFR assumed all emergency medical care and

transport. Continued changes in pre-hospital medical care required a higher level of both

BLS and ALS response each using several different staffing options. IEMS, Inc., as the

medical oversight agency required Lincoln Fire and Rescue (LFR) to evaluate a different

firefighter/paramedic staffing model than what was currently being used to provide BLS


and ALS services to the citizens of Lincoln, NE. (personal communication, May 5, 2004).

This letter is found in Appendix E. The research problem is that no evaluation criterion

exists for LFR to determine the overall impact of different firefighter/paramedic staffing

models. The research purpose is to identify criteria to determine the overall impact of

different firefighter/paramedic staffing models to the citizens of Lincoln and LFR.

An evaluative research method was used to gather information on the standards for

firefighter/paramedic staffing models. Questionnaires, observations and interviews were

used to gather information from other organizations and LFR employees to answer the

following research questions:

1.

2.

3.

4.

5.

What, if any, are the fire/EMS national standards for firefighter/paramedic staffing?

What, if any, are the fire/EMS local standards for firefighter/paramedic staffing?

What, if any, criteria have departments of similar size used in implementing a

firefighter/paramedic rotation system?

What, if any, are the similarities and differences between the current and proposed

LFR firefighter/paramedic staffing models?

What are the issues that LFR need to address when evaluating the impact of

different firefighter/paramedic staffing models?

Background and Significance

Lincoln Fire & Rescue has a long history of providing EMS response and care to

the Lincoln community. LFR is a multi-focus agency providing fire suppression and EMS

services along with a variety of rescue and all-hazards response capability. Basic medical

response began in the mid 70’s and evolved to more advance care to eventually include the

use of heart monitors and defibrillation for heart attacks. Nationally, EMS responses from


fire departments around the country amount to approximately 80% of all calls (Metro,

2003). Since approximately 73% of total calls for LFR services involved medical

response, the goal of the department focused upon providing first response to patient’s side

within 4.08 minutes (LFR, 2004). This was accomplished by placing a cross-trained

firefighter/paramedic on each engine company. Firefighter/paramedic training began in the

spring of 1994. By July 1997, 48 firefighter/paramedics were assigned to 14 engine

companies to provide ALS care.

A partnership existed between the public supported fire department and the private

ambulance company, Rural Metro. LFR provided the first response to all BLS and ALS

medical calls from the 14 fire station locations while the ambulance company provided

BLS and ALS care and transportation to medical facilities from 3 station locations. With

the exception of medical transportation, it became evident that this response configuration

had created a duplication of patient care services. Firefighter/paramedics from LFR were

first to provide care, but were transferring patient care to Rural Metro for continued care

and transport. Only on occasion would LFR firefighter/paramedics continue to provide

care to a patient through to his or her delivery to the hospital emergency department. This

configuration created two classes of firefighter/paramedics; the Quick Response Team

(QRT) firefighter/paramedic staffed on fire suppression engine companies and those who

were system certified paramedics qualified to provide ALS ambulance transport. Because

of limited patient contact time, QRT firefighter/paramedics were lacking experience and

hesitant or not allowed to practice to their full capabilities

Medical oversight in the Lincoln system is provided by the non-profit agency,

EMS, Inc. that takes direction and reports to a board of directors consisting of emergency


physicians, citizens and business leaders. All emergency medical care from responders in

the service area of the City of Lincoln and Lancaster County operate, as a privilege, under

the medical license of the EMS, Inc. Medical Director. The goal of EMS Inc. is to provide

medical direction, monitor the emergency 911 system and assure training and quality

assurance to the emergency and non-emergency medical system. (EMS Inc., 2004)

LFR firefighter/paramedics are all nationally registered and must be system

certified by completing minimum levels of training, continuing education, complete an

internship with a system preceptor and earn final approval by the Medical Director.

System preception is usually provided by current system firefighter/paramedics that have;

applied to the Medical Director, found to have a high skill level, the ability to mentor and

are experienced in this system. Medical preception for an intern depends on each

individual paramedic, but typically takes from 2-6 months.

By Spring 2000, many citizens and community leaders also felt that a duplication of

medical services were present between Rural Metro and LFR. Later that year, Rural Metro

lost a public election referendum to continue to provide emergency medical services in the

City of Lincoln. LFR immediately prepared to provide the additional services of medical

transportation by purchasing ten ambulances and hiring ten paramedics to fully staff the

anticipated service. On January 1, 2001, LFR assumed all emergent (911) BLS and ALS

medical care and transport in the Lincoln community (City of Lincoln, 2000).

Emergency Medical Dispatching (EMD) was implemented in January 1999. All

911 medical calls were triaged by a dispatch call taker and then classified based on urgency

ranging from minor to life threatening so appropriate resources could be sent. Medical

response configurations for all 911 calls required one engine company and one ambulance.


Staffing configurations for each engine company consisted of 2-3 EMT’s and one

paramedic. Ambulance staffing consisted of one EMT driver and one paramedic. On all

ALS or critical calls categorized as Delta and Echo, the Medical Director requires both the

engine firefighter/paramedic and ambulance firefighter/paramedic provide care for the

patient until delivery to the hospital. The requirement of two paramedics on all critical

calls is currently an established protocol from the Medical Director (EMS, Inc, August 24,

2004).

The transition of ambulance service from a private provider to LFR occurred with

only minor problems. Medical oversight from EMS, Inc. was a prominent factor in system

quality assurance. Continued system improvements were researched and several staffing

configurations and response options were considered. In 2001, EMS, Inc. conducted a

system-wide survey of all aspects of pre-hospital emergency medical care. Feedback was

solicited from 911 dispatchers, pre-hospital providers, hospital emergency department staff

and rural fire departments. Specific to this survey were questions that addressed

ambulance staffing. According to the survey results, “many paramedics indicated that they

would prefer to have two paramedics on each ambulance” (EMS, Inc., 2002, p.7) It was

felt by many of the paramedics who responded to the survey that several questions were

misleading and did not clarify any particular ambulance configuration. EMS, Inc.,

however interpreted the survey results, that the medics were asking for a change in the

staffing configurations of the ambulances to include two firefighter/paramedics on each

ambulance. LFR firefighter/paramedics felt they did in fact want to have two

firefighter/paramedics on critical calls, but not have two firefighter/paramedics

permanently assigned to each ambulance. Two firefighter/paramedics assigned to each


ambulance would require an even greater amount of time responding to EMS demands and

less time for training, fire suppression activities and very little respite from the high call

volume.

The EMS, Inc. director at the time of the controversial survey convinced the

Medical Director and oversight board that a two-firefighter/paramedic per ambulance

configuration needed to be implemented and preparations were made by LFR to carry out

the request. C-shift was chosen for the study because the number of transport capable

medics was closest to the desired staffing level of 20 firefighter/paramedics per duty shift.

A letter dated May 5, 2004, Appendix E, referencing the “trial of pairing

paramedics on medic units” specified that the study would be conducted for two complete

work cycles (8 working sets) or the equivalent of approximately six months. EMS, Inc.

was particularly interested in provider satisfaction (Based on Provider Survey), patient

contacts per provider, ALS skills per provider, IV and ET proficiency and cardiac arrest

statistics. The study was to be begin as soon as possible (EMS, Inc., personal

communication, May 5, 2004).

This research study will attempt to address the United States Fire Administration

(USFA) operational objective of “responding appropriately and in a timely manner to

emerging issues” (NFA, January 2004, p. 4). The evaluative research method will study

an EMS delivery system in Lincoln, NE, and EMS delivery systems from other fire

departments or agencies. Applied research will evaluate and consider protocols or

standards for staffing configurations used or proposed by other EMS systems and it will

research what is common and accepted practice. Relevance and considerations were made

from the National Fire Academy (NFA) course Executive Development, especially with


regard to Unit 3: Change Management (National Fire Academy [NFA], 2004, pp 3-1 to 3-

32) and Unit 4: Research (NFA, 2004, pp. 4-1 to 4-23).

Literature Review The literature review for this ARP began at the Learning Resource Center (LRC)

for the NFA in May 2004. The research focus was to attempt to gather current and relative

information regarding national standards in staffing criteria for paramedics and medical

response, without duplication of research. Several factors thought to be significant reasons

for conducting rotations were discovered. Literature review continued with local and

internet resources relative to The City of Lincoln and the State of Nebraska.

Firefighter/paramedic staffing configurations vary as widely as there are medical

response systems. Standards exist as general guidance and are usually found to support the

various services provided by either a private or public sector entity. Fire based EMS

systems are addressed through standards from the National Fire Protection Association

(NFPA, 2001) in Organization and Deployment of Fire Suppression Operations,

Emergency Medical Operations and Special Operations to the Public by Career

Departments, NFPA 1710, 2001 Edition. NFPA 1710 is a consensus document that

provides some general guidance for minimum staffing response to meet specific goals.

Many standards are designed with response goals based on a specified level of care needed

upon arriving at the patient’s side and within a specified amount of time. Agencies monitor

this time-based response known as fractile analysis to determine averages in achieving

system goals (IAFF, 1999, 2003, p. 63). System administrators can then translate this to

resources such as adequate personnel numbers, staffing configurations and response

vehicles.


The International Association of Fire Fighters (IAFF) when studying the

measurement of quality and effectiveness in pre-hospital EMS care finds that standards

exist on a voluntary basis but most importantly, they are developed as a consensus of many

associated agencies relating to every aspect of EMS service delivery (IAFF, 2003). The

thought of standards being termed voluntary begins to diminish when the following

interpretation is considered:

Standards that have been developed by a governmental authority at any level carry

the force of the law for the jurisdiction. These include everything from local

ordinances or charter clauses establishing response time standards to state

regulation for training and licensing of EMS providers ( p. 43).

Standards require responding personnel to any EMS incident be trained and

qualified to provide the level of care necessary and provide transportation as required by

the department. Service levels are described as BLS for first responder care and standards

recommend staffing provide a 4-minute response time for 90 percent of the calls. For an

ALS response, the benchmark for meeting the response goals is 8-minutes, 90 percent of

the time. NFPA 1710 recommends that “Personnel deployed to ALS emergency responses

shall include a minimum of two members trained at the emergency medical technician –

paramedic level and two members trained at the emergency medical technician – basic

level arriving on scene within the established response time.” (NFPA, 2001, A.5.3.3.4.3).

LFR is a fully accredited department through the Commission on Fire Accreditation

International (CFAI, 1197-2000) since 1997. CFAI is a private, non-profit entity for fire

and emergency service departments intending to complete self-assessments to achieve

accreditation. Benchmarks or criterion and performance indicators are established by


CFAI to provide guidance standards, allowing agencies to seek continuous improvements

for their own organizations and the communities they serve. The self-assessment process

uses specific criterion for each aspect of the organization with several core competencies,

assuring compliance to minimum standards during the evaluation process. Criterion 5G:

Emergency Medical Services (EMS) asks for verification that LFR has an EMS program

providing the community with BLS and ALS out-of-hospital emergency medical care.

Core competency 5G.1 then requires that agencies meet their response time objectives for

medical response based on that level of care (CFAI, 1997-2000, p 5.16). Core Competency

5G.5 seeks verification on standard operating policies and protocols to meet the needs of

the service level of response. All are vital to the provision of quality care, but specific to

this research is the core competency performance indicator 5G.2 “There is adequate

staffing to meet agency objectives” (CFAI, 1997-2000, p 5.16).

Private out-of-hospital medical care providers and ambulance services often refer to

non-fire based standards such as the American Ambulance Association (AAA). The

Commission on Accreditation of Ambulance Services (CAAS, 2004) also has established

response time standards of eight minutes and fifty-nine seconds, or less, 90 percent of the

time, but allow for variances at the direction of the system Medical Director (CAAS, 2004).

In an effort to find staffing recommendations from the medical community, internet

research was conducted on staffing recommendations. The American College of

Emergency Physicians (ACEP) has a policy statement approved by the Board of Directors

in March 1999 referring to a decision for local Medical Directors to Staff Ambulances.

The ACEP believes that staffing of ambulances providing BLS or ALS care should be at

the discretion of the local Medical Director. “Decisions made regarding the number and


qualifications of personnel providing care, above regulatory minimum standards is a patient

care issue” (ACEP, 1999, ¶ 1).

The American Heart Association (AHA) has always advocated for quick action by

responders in the event of a heart attack. The fastest response would logically relate to

more EMS resources located strategically closest to any patient. Pepe’s study (as cited in

Chandra & Hazinski, 1997) found that additional responders should treat cardiac arrest

cases because of the difficulties in providing care in the field. “In those systems that have

attained survival rates higher than 20 percent for patients with ventricular fibrillation,

response teams include, as a minimum, two ALS providers and two BLS providers.”

(Chandra & Hazinski, 1997, p. 1-6). They do not indicate a specific staffing configuration

to accomplish this goal.

As demand on EMS systems increase, some considerations must be made to

determine if all medical responses need an ALS provider. Most communities recognize an

increasing EMS response volume. Because of simple economics or resource management,

they have taken some steps to address the issue. Emergency Medical Dispatching (EMD)

or prioritizing medical calls by a triage method can then effectively dispatch an appropriate

BLS and/or ALS response. In efforts to provide quality and efficient care, a study of Fire-

Based EMS (IAFF, 2003) states:

Over 98% of the 200 most populous cities in the U.S. provide at least some level of

ALS care, and the trend over the last five years has been shown an increase in ALS

coverage. There is some controversy, however, regarding whether busy EMS

systems should staff all ambulances with ALS providers (all-ALS system) or with a

combination of ALS and BLS crews (tiering) (p. 30-31).


Most national standards for EMS systems address service levels to meet a standard

of care and require arriving at the patient in a specified period and in a specific number

(percent) of responses. Research of national standards on EMS staffing found no absolute

requirement but rather standards and recommendations relating to specific staffing

configurations.

To address any local fire/EMS standards, research was done primarily on the

internet since both the City of Lincoln and State of Nebraska agencies have policies and

regulations posted for public access and review. The State of Nebraska agency with

regulatory control of out-of-hospital EMS is the Department of Health and Human Services

(HHS). Statutes Pertaining to Emergency Medical Services (c) Emergency Medical

Services Act, “71-5186, Ambulance; transportation requirement,” states that when

transporting patients, the ambulance “is occupied by at least one certified out-of-hospital

emergency care provider.” (State of Nebraska, 1998, p. 5). Additionally, the Emergency

Medical Services Act requires a Medical Director for each system with authorization to

implement and modify protocols, operating procedures and guidelines in order to provide

efficient and effective out-of-hospital medical care.

On the local level, the Lincoln Municipal code has implemented city ordinance with

reference to the Ambulance Transportation Code, “7.04.080, Emergency Medical Services

Oversight Authority (EMSOA)”. By ordinance, ambulance transport, protocols and

medical control are governed by the EMSOA for any medical services provided by the fire

department. The Medical Director is also contracted with EMSOA “for the purpose of

providing medical direction and control for out-of-hospital emergency medical care by

personnel providing ambulance service.” (City of Lincoln, 2000). The ordinance also


contains response time objectives (ambulance only) for life-threatening EMS calls to be

with the patient within eight minutes from time of dispatch for at least 90 percent of the

responses. Six minutes is desired but the response objectives are for evaluation of quality

assurance.

EMS, Inc. has developed System Policies and Procedures to offer guidance and

direction to all EMS response in Lincoln and the surrounding service area. Policy #12,

Response Requirements further specifies in item #3 that “For any city or county emergency

dispatch coded Delta or Echo it is mandatory that two paramedics must be immediately

dispatched to the call. The paramedics can be on separate units, but the units must be

dispatched immediately” (EMS, Inc., 2004, p. 15). LFR must adhere to this general

direction

Nebraska State Statute(35-302, 1979, ¶ 1), titled “Paid fire departments;

firefighters; hours of duty; alternating day schedule,” requires that for firefighters of paid

fire departments, “Each single-duty shift shall consist of twenty-four consecutive hours”

(State of Nebraska, 1979). LFR abides by state law with all fire suppression personnel

including firefighter/paramedics working a 24-hour shift with 24 hours off duty for seven

duty shifts followed by eight “Kelly” days off-duty.

Another research question in this ARP seeks information and criteria for staffing

rotations from other departments of similar size. Literature research found several sources

with common indicators of a need to proactively address physical, mental and emotional

stress of emergency responders. Paramedics in particular seem to suffer a greater

frequency of stress from high call volumes and continued exposure to traumatic events.

They also tend to take on a greater responsibility for patient care and outcome and are in


longer patient-provider relationship than BLS responders. (Boudreaux, Mandry, Brantley,

1997; Cannon, 1988; and Paton and Violanti, 1996).

A telephone interview was conducted with captain David Andersen of SFFD. He

is an author, NREMT-P, and in charge of clinical research and performance management

for SFFD. His comments were specific to the SFFD Rapid Paramedic Response System

Final Report (RPRS Project) and showed a direct correlation to two specific

firefighter/paramedic staffing configuration considered by LFR. The information he

provided detailed experiences from an approximate one-year study considering similarities

and differences of both systems (Andersen, D. personal telephone interview, June 15,

2004).

The San Francisco (CA) Fire Department (SFFD) in 2002 completed a study of a

split-paramedic response model where “the traditional two-paramedic team is split between

two units. One paramedic staffs the first responder apparatus or company in SFFD

parlance. Ambulances are staffed by one paramedic and one basic EMT with supplemental

training.” (Andersen, 2004, p. 28). Even though demographics were not comparable to

Lincoln, this study proved significant for this ARP for two reasons. First, the split-

paramedic response model that SFFD was testing is the configuration that LFR has been

providing to citizens since beginning ambulance transport services in 2001. Secondly, the

original response configuration from SFFD before the pilot study was a BLS first response

by fire suppression apparatus with dual paramedic transport units. This dual paramedic

response configuration was the proposal for LFR to implement as directed by EMS, Inc.

Based on that proposal, the Medical Director had proposed that LFR implement a six-

month study.


The San Diego Fire Department (SDFD) recognized in the mid-80’s that

paramedics were being subjected to the stress and fatigue of high call volume especially at

busy companies. They also found that paramedics in outlying stations had fewer

opportunities to maintain clinical skills due to lower call volume. After study and

consideration, they successfully proposed and implemented a rotation between high and

low call volume on a three station or “triad” model. The rotation changed every twelve

shifts or about one rotation per month. The twelve-shift schedule was thought to be

adequate for skills maintenance and offering stability to each crew. “Two-medics would be

assigned per shift to the ambulance unit and the third to the engine company. An in-house

rotation between the ambulance and the engine company would allow maintenance of skills

on both units and an additional way to take a break from stressful medical response”

(Cannon, 1988, p. 39).

EMS standards rely on response times and other relevant data. The LFR database

was a valuable resource for comparative information between the local response goals and

recognized national standards. Mr. Ken Joyce, systems/programmer for LFR was helpful

in providing statistical data for this project (Joyce, personal communications October 8,

2004).

Literature Review Summary

The literature review provides adequate information to support consensus standards

and regulatory guidance on local, state and national levels for general EMS response. It is

important to note that such requirements are minimum standards to address very broad

goals and objectives for every conceivable system. It is also apparent that the local

regulatory agency and specifically the Medical Director has legal authority by ordinance to


request appropriate staffing configurations based on the needs of the EMS service agency

and the patient care issues.

Paramedic staffing configurations vary widely based on several prominent factors;

community and department size, call volume and the provided level of care

(BLS or ALS). Administrative or provider preferences however were the most significant

reason. All configurations accomplished the same or similar patient care goals.

Finally, the literature review provides information to determine the overall impact

of different firefighter/paramedic staffing configurations to the citizens of Lincoln and

LFR. Sufficient material was found to address the research questions for this ARP.

Procedures

Extensive use of definitions and terms were used throughout this paper. They can

be found in Appendix A.

This research project uses an evaluative method of research to gather information

relating to standards for firefighter/paramedic staffing models. Published literature and

internet sources were researched for information and as a background for evaluating

differences. Some information was acquired through interviews of individuals who had

knowledge of specific staffing configurations that LFR was considering. Questionnaires

were used to gather information from other organizations.

Research for this ARP began at the Learning Resource Center (LRC) in May 2004

while attending the NFA in Emmitsburg, MD. Literature review continued with the library

resources of LFR, the University of Nebraska and the Lincoln Public Libraries. Internet

research was also used primarily for access to laws, statutes, ordinances and reference

libraries of periodicals such as Journal of Emergency Medical Services (JEMS) and various


professional organizations of the International Association of Fire Fighters (IAFF),

American Ambulance Association (AAA), Lincoln Medical Education Foundation

(LMEF), EMS. Inc., American College of Emergency Physicians (ACEP) and others.

One important area of this research relies on information gathered from other

agencies. For this aspect of research, a questionnaire was conducted for specific

information relative to firefighter/paramedic staffing configurations. A commercial

internet based questionnaire instrument called Zoomerang© was used via e-mail

distribution on September 7, 2004. It should be noted that Zoomerang© calls their

instrument a “survey”. A questionnaire introduction message was sent with a link to the

actual questionnaire. The questionnaire was sent to 27 EFO students primarily from the

May 17-28, 2004 NFA Executive Development course. Fourteen of the 27 questionnaires

were completed and received in the tabulation results summary of the Zoomerang© return

file. The questionnaire consisted of twelve questions to determine demographics, EMS

capabilities and staffing configurations or rotations.

Returned results of this questionnaire indicated that demographics and rotation

configurations were limiting and did not meet the satisfaction of this study. For this reason,

an identical questionnaire was distributed to another group of twenty individuals from

organizations thought to provide information relative to paramedic rotation models as

opposed to simply meeting the criteria of like and similar size. This second Zoomerang©

survey was sent via e-mail on October 13, 2004 with a request to complete and return by

October 20, 2004. Both questionnaires were identical and a copy of the questions can be

found in Appendix B. The second questionnaire was sent after a poor response rate of only

56% or 14 out of 27 returning results. Results from the second questionnaire were equally


disappointing with only three returned out of 20 sent. Combined results of both

questionnaires were approximately 37% or 17 of 46 total sent. The second questionnaire

was sent to a random list of EFO program participants. A list of departments responding to

both questionnaires can be found in Appendix C.

Limitations.

Some limitations seemed apparent when conducting research. The City of Lincoln

is located in the Midwest where few fire departments are of comparative size offering the

same or similar EMS response. With a need for more information, it was necessary to rely

on questionnaires that reached beyond the parameter of like, similar, and geographic

location. The problem of questioning outside the Midwest has the potential of skewing

aspects of staffing configurations, labor costs or other factors potentially found in

jurisdictions outside the Midwest.

A low return rate from the initial questionnaire caused a second to be sent with

equally disappointing results. Initially it was thought that a web-based questionnaire would

be used with the intent that respondents would find it less imposing and a relatively easy

response. It is assumed that this is not the case and for a variety of reasons, response was

lower than anticipated. Due to time constraints, it was not possible to repeat a more

comprehensive distribution of questionnaires for this study.

An internal questionnaire for LFR firefighter/paramedics and their supervising

captains was developed to provide insight, concerns and possible alternative staffing

configurations. Time limitations prevented an in-depth study with LFR employees since

the six-month LFR proposed paramedic staffing configuration study would not have been


complete before completion of this ARP. The draft questionnaire is formatted for

Zoomerang© distribution and a copy can be found in Appendix D.

Results

This ARP is a result of a firefighter/paramedic staffing change on ambulances

within the LFR emergency medical response system. This change was a requirement of the

system Medical Director, medical oversight agency (EMS, Inc.), and the board of directors.

The staffing configuration of two firefighter/paramedics on each ambulance had been a

system goal by this consortium for several years. A unified decision was made to conduct

a 6-month study to determine relevance of a two-medic staffing configuration in the

Lincoln system. This study would be limited to the emergency medical response staffing

on one shift (C-shift), staffed with an adequate number of firefighter/paramedics to reflect a

valid study.

Research Question 1. What, if any, are the fire/EMS national standards for

firefighter/paramedic staffing?

National standards are sometimes considered minimum (standards) and are found in

several sources with regard to response to ALS and BLS out-of-hospital medical response

(NFPA, 2001), (IAFF, 2003), and (CAAS, 2004). The typical response time is from receipt

of a call for help to the arrival of BLS medical care is within 4-minutes to 90 percent of the

incidents. ALS response is expected within 8-minutes to 90 percent of the incidents. In

order to complete specific medical care for heart attack and ventricular fibrillation, the

minimum staffing determined by AHA is two BLS providers and two ALS providers

(Chandra & Hazinski, 1997, p. 1-6).


In 2002, LFR completed their second CFAI accreditation review including a site

verification visit. Specific to accreditation review was Criterion 5G: Emergency Medical

Services (EMS). All compliance areas were completed to the satisfaction of evaluators

including the question of adequate staffing. “Depending on firefighter absences, a medical

emergency call will place a company officer (EMT), two paramedics, and two to three

firefighters (EMT) at the patient’s side” (LFR, 2002, p. 137). The specific configuration is

not defined, but the appraisal states “Staffing is adequate to provide efficient care to

victims of illness or injury within the City of Lincoln” (LFR, 2002, p. 137).

Nationally, physicians groups offer policy statements through the ACEP and

confirm the need for appropriate staffing configurations and levels. Their position states

that Medical Directors have authority to exercise specific configuration decisions based on

local needs (ACEP, 2004).

The literature review indicated concepts of tiered response using BLS and ALS

responders. LFR statistics show that in 2003, approximately 33% of total EMS response

was for ALS care (LFR, 2004). A tiered response occurs when LFR is dispatched for BLS

medical services by sending the closest BLS engine company with an ambulance for

transportation. The ambulance is always staffed with a firefighter/paramedic for ALS care

and there is no staffing allocation for an ambulance at the BLS level of care. In 2003,

approximately 67% of medical calls for service in the Lincoln system require only a BLS

response with EMT’s and firefighter/paramedics were not needed. A change to provide a

BLS response and transport component is currently under consideration.

Some argument on staffing issues contends there is little cost saving to providing a

BLS ambulance as opposed to an ALS unit (IAFF, 2003). In the LFR system, cost


differences for EMS service delivery would only be the salary difference between a

firefighter/EMT and a firefighter/paramedic, which is currently $2.15 per hour average

(City of Lincoln, 2004, p 6). The insignificant savings in cost difference between the two

levels of service may not be acceptable to goals of LFR and the citizen taxpayer. It is

believed that ALS care by a firefighter/paramedic would be worth the additional cost over

BLS care.

Research Question 2. What, if any, are the fire/EMS local standards for

firefighter/paramedic staffing?

Minimum standards with regard to response and staffing levels are also found in

state and local ordinance and are intended to offer direction to local jurisdictions

(Nebraska, 1998) and (City of Lincoln, 2000). Nebraska State and local standards seem to

be a reflection of national standards with few notable exceptions or additions. As with

national standards, the local Medical Director has authority to require staffing

configurations based on local needs (IAFF, 2003, p. 43). A common theme on national,

state and local minimum standards is to offer guidance for staffing levels and resource

allocation in order to achieve the response goals as outlined in these documents.

The medical oversight agency, EMS. Inc. and the Medical Director have stipulated

that LFR respond to EMS calls categorized Delta and Echo (critical ALS) with two

firefighter/paramedics (EMS, Inc. 2004, p. 6a). There are essentially two viable

configurations available to meet this criterion. The first is one firefighter/paramedic

responding on the closest engine company with the second firefighter/paramedic arriving

with the ambulance. The second configuration is for both firefighter/paramedics to arrive

on the ambulance. These two staffing configurations are at the center of this ARP. The


questionnaire (Appendix B) indicated from response agencies that little difference exists

between staffing levels or configurations between BLS and ALS response from questions

eight and nine.

One purpose of the questionnaire was to assure that any EMS delivery system LFR

used would meet national standards and would indicate if a national consensus were being

following. Comparison was necessary to meet response goals of LFR and satisfy goals of

the Medical Director and EMS, Inc. Since literature review indicated only general

recommendations for alternate staffing configurations, it was hoped that different staffing

configurations would be discovered and system problems or possible solutions to problems

could be identified.

Literature research, questionnaires and comparative analysis all indicate that there is

a need to address not only stress, but also training, response times, skills assessment and

respite issues with regard to any paramedic staffing configurations. Informal observations

of LFR firefighter/paramedics and reviews of call volume indicated higher levels of stress

and an unbalanced workload between employees. A common solution to relieve stress due

to high call volumes is to reduce the number of hours of on-duty time, resulting in shorter

work periods with more frequent time off. Nebraska State statute clearly stipulates that

firefighters (and firefighter/paramedics) are required to work a twenty-four hour duty shift

(Nebraska, 1979). Zoomerang© questionnaire item four asks whether

firefighter/paramedics in the respondent’s system works a twenty-four hour shift. It further

indicates that 65% of responding departments have paramedics that work a 24-hour shift.

Other responses to this question indicate 35% either had no paramedics or worked a

schedule other than 24-hour shifts.


In Zoomerang© questionnaire item seven (Appendix B), respondents were asked to

indicate the type of EMS services provided by the fire department in their community. All

respondents provided some form of medical response with 70% providing ALS care.

There were 29% providing both ALS care and transport with a fire department ambulance.

One department provided ALS care with paramedics but only transported if the private

ambulance company was not available.

Item eight of the Zoomerang© questionnaire requested specific configurations for

EMT’s and firefighter/paramedics to a BLS response. Fire suppression vehicle staffing

found 88% had at least one responding EMT with 59% of the total response had staffed at

least three responding EMT’s. Fifty-two percent had 1-2 EMT’s on staffing an ambulance

while 47% had none. Paramedics were staffed on 41% of fire suppression vehicles and

52% had no paramedics assigned. Seventy percent of ambulances responding to BLS calls

had 1-3 paramedics assigned with 29% having no fire department paramedics on BLS

ambulances.

Item nine of the Zoomerang© questionnaire requested specific configurations for

EMT’s and firefighter/paramedics to an ALS response. Fire suppression vehicle staffing

has 1-4 EMT’s on 76% of the respondents with 11% having none. Forty Seven percent

staff ALS ambulances with at least one EMT and 52% have no EMT”S assigned to an ALS

ambulance. Fire suppression vehicles with a paramedic assigned were found in 41% of the

departments and 52% had staffed no paramedics. Seventy percent of ALS ambulances

were staffed with 1-3 paramedics with 29% not staffed with paramedics. When comparing

questions eight and nine, it seems that staffing configurations for BLS services were almost

identical to configurations for ALS services in those responding departments.


Research Question 3. What, if any, criteria have departments of similar size used in

implementing a firefighter/paramedic rotation system?

Limited staffing configuration studies were found in literature review and although

the SFFD or SDFD has merit to differing staffing configurations, they do not meet the

criteria for like and similar size to Lincoln. Questionnaire items one, two, and three all

relate to demographics such as city name, community size, and type of department (career,

volunteer, combination career/volunteer or other for private, military or other agencies. A

major number of respondents (76%) were from career departments with only 23%

representing combination career/volunteer departments. The majority, however service a

smaller population base (less than 50,000) as compared to Lincoln’s population of 235,594.

Research Question 4. What, if any, are the similarities and differences between the current

and proposed LFR firefighter/paramedic staffing models? Literature review shows a

specific staffing configuration for the SFFD after a one-year study. The initial

configuration for SFFD was to concentrate two paramedics on each ambulance. They

completed a one-year study in December 2002 using a “split-paramedic” response to ALS

calls. The study configuration consisted of one paramedic and one EMT on each

ambulance. Other paramedics were staffed on first responding engine companies. The

SFFD study showed a “split-paramedic” response to the patient by a paramedic was sooner

than the concentrated two-medic response. They also found teamwork between paramedics

and EMT’s had no adverse effect on patient care. (SFFD, 2003).

The SDFD triad rotation system used a staffing configuration of two paramedics on each

ambulance with a third paramedic staffed on an engine company. A twelve-shift rotation

was facilitated between two other fire stations, all with differing call volumes. The


interesting aspect to this configuration is that it is contrary to the SFFD model where an

EMT and paramedic are paired on ALS ambulances. The SDFD model is the staffing

configuration required by EMS, Inc. and the Medical Director of the LFR system.

Zoomerang© questionnaire item five asks respondents for the approximate number

of calls paramedics will respond to in a twenty-four hour shift. This question is important

to establish if call volume is a factor in staffing configurations and shows that a majority of

paramedics responded to between 6 and 15 calls in a 24-hour shift. Results showed 29%

were in the 6-10 call range, and 17% in the 11-15 calls per 24-hour shift. Two respondents

showed a high call volume of 16-20 calls per 24-hour shift for their jurisdiction. Twenty-

nine percent have no paramedics representing their department.

Question 6 is an attempt to correlate call volumes with the total time required for

each call from dispatch through completion of reports. Respondents indicated that 76%

logged 30-60 minutes per call and another 12% were actually over one hour.

Questionnaire item ten seeks to determine if the respondent’s organizations rotate

firefighter/paramedics from engine companies or truck companies to ambulance or

transport units. Paramedics rotated from an ambulance to engine or truck companies in

29% on a routine basis while a majority (70%) does not have a rotation policy. Response

numbers usually are a determining factor if rotation models exist and questionnaire item

eleven asks affirmative respondents to specify a rotation pattern or frequency. When asked

the pattern or frequency for paramedic rotations, 6% rotated every-other 24-hour duty shift

and 17% rotated every 2-3 duty shifts. Twelve percent had no scheduled rotation. The

balance either did not rotate or did not have paramedics. One department rotated but it was

based on first meeting an hourly minimum per month.


Research Question 5. What are the issues that LFR need to address when evaluating the

impact of different firefighter/paramedic staffing models?

Literature review consistently addressed various problems and concerns with

staffing ambulance transport units, firefighter/paramedic stress and “burnout”, and

maintenance of medical skills (Boudreaux, Mandry, Brantley, 1997; Cannon, 1988; and

Paton and Violanti, 1996). All indicate these points are essential for a quality EMS service.

Questionnaire item twelve validates some LFR concerns and indicate the need for

rotation. Other EMS systems have indicated the major reasons for rotations to be 18% for

stress reduction, and 18% to complete training requirements. However, 41% is to balance

the workload. For those respondents who did rotate paramedics, one department uses an

annual bid for openings on different apparatus and another rotates to maintain paramedic

skills proficiency.

One valuable aspect of the questionnaire related to reasons for the rotations. For

example, in comparing call volume from question five with the approximate average time

for each call in question six could show actual time on medical calls to be as high as 20

hours in a 24-hour shift. This information helps to confirm suspicions of stress as being a

significant factor for considering firefighter/paramedic rotations.

Discussion

After reviewing Unit 3, Change Management (NFA, 2004, pp. 3-1 to 3-32), it is

important to note that one of the most difficult issues for any organization is to cope with

change. LFR is faced with a firefighter/paramedic staffing change that may be

uncomfortable to facilitate, difficult to manage and out of employee’s personal and direct


control. Patient care is still within their control and it is imperative that the only acceptable

change in patient care is for overall system wide improvement.

Question one asks, what were the fire/EMS national standards for

firefighter/paramedic staffing and it was confirmed that there are national standards and

recommendations from a variety of standards groups and accreditation agencies such as

NFPA 1710, AHA, CFAI and CAAS. The recommendations are for EMS responding

agencies to provide adequate resources for appropriate patient care. There is a

differentiation between BLS and ALS care with skill levels consistent from EMT to

paramedic configurations or acceptable combinations. Examples can be found in (NFPA,

2001), (Chandra & Hazinski, 1997), (CFAI, 1997-2000) and (CAAS, 2004). The current

EMS response model for LFR follows these requirements and standards. The proposed

configuration of two firefighter/paramedics to an ambulance would also follow the national

standards. Research found there are standards or benchmarks for staffing levels, but

nothing specific to meet response objectives.

Response standards are an important factor in the delivery of medical care, since it

is apparent that a standard of care be determined as a benchmark, but realizing the fact that

local jurisdictions are limited geographically in rural or remote areas. Such limitations also

exist in both appropriately trained personnel and resources to the same challenges. In other

words, very few jurisdictions have the resources to provide a fully equipped and staffed

ambulance waiting for every call in every location to meet every aspect of the response

standards. Minimum standards exist as a goal and benchmark for communities when

planning and considering adequate and appropriate EMS response.


According to Nebraska state statute and local protocols, both the current and

proposed change in staffing configurations meet appropriate response standards. No

specific response configuration is noted in state statutes, (State of Nebraska, 1998) but

EMS, Inc. specifies that two paramedics must be dispatched to all Delta and Echo (critical

ALS) calls (EMS, Inc. 2004). One of the options for staffing configurations might be to

offer a different work schedule to reduce the long twenty-four hour shift schedule to eight,

ten or twelve hours. Nebraska state law prohibits firefighters or firefighter/paramedics to

be scheduled in less than 24-hour increments (State of Nebraska, 1979). Changing the

work schedule is not an easy option, since it would violate the current state statute. The

only options would be to change the law or re-classify firefighter/paramedics and remove

their firefighting responsibilities. This could be a demoralizing action since most

firefighter/paramedics enjoy the diversity of their firefighting responsibilities.

The two-tiered level of care between LFR system certified firefighter/paramedics

and QRT firefighter/paramedics was problematic since a quality assurance issue existed

between the two skill levels. This eventually became a system goal to raise the level of

care for each firefighter/paramedic to be system certified. This goal for LFR will be

accomplished soon.

Even though San Francisco Fire Department and San Diego Fire Department are

larger communities with many differences, the EMS delivery systems seemed applicable to

Lincoln. The SFFD one-year study proved that a decentralized approach was able to get

ALS care to patient’s side quicker than a two-medic configuration. It also proved that

paramedic skills were maintained through a form of rotation schedule that met their needs

(SFFD, 2003). This staffing configuration was particularly important to the LFR study


since it was a proven study supporting the current LFR configuration as opposed to the two

firefighter/paramedic proposal. Andersen (personal communication, June 15, 2004)

claimed there was “no comparison” when comparing the split response as opposed to

concentrating medics on ambulance units. “We can get a higher level of care to patients

quicker.”

The SDFD study was also important to the LFR study since it outlined a specific

firefighter/paramedic rotation from busy medic companies to slower engine companies.

Unlike the current EMT/paramedic LFR configuration, their study did staff each

ambulance company with two paramedics (Cannon, 1988). Review from the SDFD study

indicates a need for stress relief for firefighter/paramedics, to maintain medical skills,

balance the workload or call volume between busy and slower units.

Three important aspects of the SDFD model are significant to the LFR staffing

requirement. Increasing call volumes for ambulances in Lincoln seem to be leading to high

stress levels in firefighter/paramedics. Skill levels of firefighter/paramedics on engine

companies in outlying areas are thought to be inadequate due to fewer patient contacts from

lower call volumes. In addition, a firefighter/paramedic rotation system would balance the

workload between busy and slower companies. Some aspects of LFR statistical analysis

led to unconfirmed signs of excess leave due to sickness, often considered a sign of

increased work related stress. This was another indication for the need to gather relevant

information by questionnaire from LFR firefighter/paramedics. These indications were

significant enough to develop an internal questionnaire for firefighter/paramedics to help

determine employee satisfaction and issues as is reflected in question design shown in

Appendix D.


Response to questionnaires sent to other fire departments indicates that some

rotation configurations exist, but they seem to be without a set pattern or specific schedule.

Since this is the case, it would indicate that little study has been done with regard to

firefighter/paramedic rotations. Affirmative response to questions addressing work stress

indicates a common need for stress management, especially for high call volume

responders. The SDFD study showed firefighter/paramedic rotations from busy companies

to a lower call volume unit was a successful stress management option.

Specific firefighter/paramedic staffing configurations are left to standard resource

management practices of LFR administration. Most LFR officials and

firefighter/paramedics disagreed with the proposed two-medic staffing configuration and

asked for the flexibility to meet the system staffing goals but without the sense of

micromanagement. LFR understood the goal, but felt that this was a poor distribution of

resources and not the best option for staffing configurations in this medical system. The

two-firefighter/paramedic staffing and rotation configuration required even more time spent

on high call volume ambulances. An overall conflict in the mission of two agencies may be

attributed to the fact that LFR is a multi-focused agency providing fire, medical and rescue

emergency response, whereby EMS, Inc. is a single focus agency concerned primarily with

out-of-hospital emergency medical response aspects.

Another side of the staffing issue was the need for firefighter/paramedics to

maintain their skills by running high call volumes consistent with the number of responses

experienced on ambulance units. Contrary to the EMS, Inc. requirement for high volume

medical response, was the complaint from firefighter/paramedics that they were unable to


complete firefighter-training requirements. They spent a great deal of time charting patient

reports and were suffering from signs of stress consistent with high call volume medic

systems such as San Diego.

A solution to consider for effective response, especially with regard to high call

volumes, is to provide a tiered response. A tiered response involves sending only BLS

medical services when EMD or the 911 dispatcher indicates it. LFR statistics showed that

firefighter/paramedics responded to a significant number of EMS calls (67%) where ALS

care is not needed (LFR, 2004). Currently, an ALS ambulance is dispatched to every call.

If a BLS transport component is added to handle the less urgent calls,

firefighter/paramedics on ALS ambulances should see some relief from the high call

volumes now experienced in the Lincoln system.

Research from literature review and questionnaires indicate a need for LFR to

address and evaluate the impact of different firefighter/paramedic staffing models.

Monitoring response times and specified ALS skills will show one aspect of system

evaluation. Questionnaires from firefighter/paramedics, their supervisors, patients, and

administrators could provide valuable information on positive aspects, problem areas and

system design. Because of findings from this ARP, a draft questionnaire has been

developed to help determine the impact of firefighter/paramedic rotations to LFR and the

citizens (Appendix D. Areas identified as a concern in other departments are most likely a

concern in the LFR system. The general areas seem to include, provider satisfaction, ALS

skills proficiency, patient contacts and cardiac arrest statistics. Provider satisfaction seems

to be a broad area and is further defined to include personal aspects and satisfaction with

the overall system.


Recommendations It is important to realize that any current or proposed firefighter/paramedic staffing

configurations would comply with, if not exceed any standards of care for EMS response.

Several options are available to meet agency goals and objectives and good management

would consider each. National, state and local standards are always essential for any

organization to maintain a high standard of care, both legally and ethically.

Recommendations include the following:

LFR follows national standards in EMS out-of-hospital care and response.

LFR should maintain accreditation through CFAI and pursue EMS accreditation through

CAAS.

LFR should monitor and improve EMS system standards through the oversight agency,

EMS, Inc. and the Medical Director.

Consideration should be made to implement firefighter/paramedic staffing configurations

and rotations from other departments.

Another external questionnaire should be sent to additional departments of like and

similar size to Lincoln to help answer research question number three. Future

distribution of questionnaires would be studied, incorporating an incentive or telephone

follow-up to increase response and wider distribution.

LFR should conduct questionnaires of firefighter/paramedics, supervisors, patients and

the administrators for system design and improvement. A comprehensive questionnaire

would help identify personnel and local issues while evaluating the impact of various

staffing models.


Study or consider a tiered response approach for non-critical BLS transportation to

relieve call volumes for ALS ambulances.

Research and implement additional stress reduction measures within LFR.

EMS care in Lincoln and most cities account for a majority of LFR’s response. With a

growing need for quality out-of-hospital EMS care and transportation, it is essential that

the system function effectively and meet local needs and community expectations.


References American College of Emergency Physicians ACEP. (March, 1999). Medical Direction for

Staffing of Ambulances. Retrieved September 22, 2004 from

http://www.acep.org/3,616,0.html

Andersen, D. NREMT-P. Split-Paramedic ALS San Francisco Cuts ALS Response Time

by Rolling First Response with 1 Paramedic and 1 EMT. fireEMS, May/June 2004,

28-33.

Boudreaux, E. MA, Mandry, C. MD, FACEP, Brantley, P.J. PhD. (1997). Stress, Job

Satisfaction, Coping and Psychological Distress Among Emergency Medical

Technicians. Prehospital and Disaster Medicine, 12(4), 9/242-16/248.

Cannon, G. A. (1988). Spreading the Wealth: A Theoretical Rotation to Relieve Burnout.”

Journal of Emergency Medical Services (JEMS) 13(3), 37-39.

Chandra, N.C. & Hazinski, M.F. (Eds.). (1997). Basic Life Support for Healthcare

Providers. Dallas, TX: American Heart Association.

City of Lincoln. (2000). Ambulance Transportation Code. Retrieved

September 22, 2004 from http://www.lincoln.ne.gov/city/attorn/lmc/ti07/ch704.pdf

_____. (2004). Agreement Between Lincoln Firefighters Association Local No. 644 of the

International Association of Firefighters. Lincoln, NE: Author.

Commission of Accreditation of Ambulance Services (CAAS). (2004) CAAS Standard for

the Accreditation of Ambulance Services, Version 2.4, June 2004.

Glenview, IL.

Commission of Fire Accreditation International (CFAI). (1997-2000). Fire &

Emergency Service Self-Assessment Manual, 6th Edition. Fairfax, VA: CFAI

http://www.acep.org/3,616,0.html

http://www.lincoln.ne.gov/city/attorn/lmc/ti07/ch704.pdf


EMS, Inc. (2002). 2002 Annual Report, EMS, Inc. Retrieved October 7, 2004, from

http://www.lincoln.ne.gov/city/fire/annual/ems/02anrpt.pdf

_____. (August 24, 2004). Emergency Medical Services, Inc. System Policies and

Procedures for Lincoln Fire & Rescue. Retrieved October 17, 2004 from

http://intralinc.lincoln.ne.gov/city/fire/mp/emspolpr.pdf

_____. (2004). Emergency Medical Services, Inc., Who we are. Retrieved

October 17, 2004 from http://www.emsinc.info/id2.htm

International Association of Fire Fighters (IAFF). (2003). Emergency Medical Services –

A Guide Book For Fire-Based Systems, (3rd. Edition). Washington, DC: Author.

Metro, M. (2003, January). Crisis in Prehospital Care. Fire Engineering’s fireEMS,

34-37.

Lincoln Fire & Rescue (LFR). (June 6, 2003). Commission on Fire Accreditation

International, Inc., Annual Compliance Report. Lincoln, NE: Author

_____. (2004). [Fire Department electronic database for recording response and

department activities]. Lincoln, NE: Lincoln Fire & Rescue [Producer and

Distributor].

National Fire Academy. (March 2004). Executive Development, (2nd ed.).

(NFA-ED-SM). Emmitsburg, MD: Author.

_____. (January 2004). Executive Development (R123) Self-Study Guide, (NFA-ED).

Emmitsburg, MD: Author.

http://www.lincoln.ne.gov/city/fire/annual/ems/02anrpt.pdf

http://intralinc.lincoln.ne.gov/city/fire/mp/emspolpr.pdf

http://www.emsinc.info/id2.htm


National Fire Protection Association. (2001). Standard for the Organization and

Development of Fire Suppression Operations, Emergency Operations, and Special

Operations to the Public by Career Fire Departments, (NFPA 1710).

Quincy, MA: NFPA.

Paton, D. PhD, Violanti, J.M. PhD. (1996). Traumatic Stress in Critical Occupations

Recognition, Consequences and Treatment. Springfield, IL: Charles C. Thomas.

San Francisco Fire Department. (April 22, 2003). Rapid Paramedic Response System –

Final Report. San Francisco, CA: Author.

State Of Nebraska. (1979). Fire Companies and Firefighters. Retrieved

September 22, 2004 from

http://statutes.unicam.state.ne.us/Corpus/statutes/chap35/R3503002.html

_____. (1997). Statutes Pertaining to Emergency Medical Services (c) Emergency

Services Act. Retrieved September 22, 2004 from

http://www.hhs.state.ne.us/crl/rcs/ems/emstat.pdf


Appendix A Definition of Terms and Acronyms

ALS: Advanced Life Support. Critical or traumatic specialized medical care provided by a

firefighter/paramedic in the Lincoln system.

BLS: Basic Life Support. Sometimes known as first responder level for medical

emergencies. Firefighter/EMT’s operate at the BLS level of care in the Lincoln

system.

EMD: Emergency Medical Dispatching. A system of triaging 911 emergency calls and

allocating resources for response. Calls are categorized from least serious to life

threatening. Alpha and Bravo are considered BLS with Charlie and Delta calls

require ALS care. Dispatchers determine the response code using caller

information cards. An Echo call is an ALS life threatening call where caller

information is obvious enough to bypass the card categorization system.

EMS, Inc.: Emergency Medical Services, Incorporated is an oversight agency for out-of-

hospital emergent and non-emergent services in the Lincoln, NE response

jurisdiction. EMS, Inc. is governed by a board of directors and contracts a Medical

Director for the system.

EMT: Emergency Medical Technician. An individual who is able to provide basic life

support (BLS) medical care. EMT is the minimum level of care for all LFR

firefighters.

EMT-P: Emergency Medical Technician – Paramedic. Also known as a paramedic or

firefighter/paramedic in the Lincoln system. They are nationally registered, provide

ALS medical care and operate under the system Medical Director.


Firefighter/paramedic: A dual trained employee skilled in both firefighting and para-

medicine.

Medic unit: An ALS ambulance staffed with at least one paramedic. In the Lincoln

system, a firefighter/EMT is assigned to drive the ambulance and assist the

firefighter/paramedic.

Out-of-hospital: Medical care and transportation as necessary provided from the call for

medical assistance to delivery of the patient to the hospital emergency department.

Preception: A mentoring system where a new firefighter/paramedic works with an

experienced firefighter/paramedic (preceptor) to obtain system certification.

Split-paramedic: Splitting a traditional 2 paramedic team to one placed on an ambulance

with the other placed on a first responding engine company. This configuration,

typically gets a higher level of care (ALS) to patient’s side quicker.

System certified: Firefighter/paramedics who have been precepted by an experienced

firefighter/paramedic and approved by the Medical Director to operate in the

Lincoln system.

Two-medic staffing configuration: Two firefighter/paramedics staffed on an ambulance.

One provides patient care and the other is assigned to drive the ambulance and

assist the other firefighter/paramedic.


Appendix B Please answer the following questions relating to evaluating changes in

firefighter/paramedic staffing. 1) The name of the community I serve is:___________________________ 2) The size of the community you serve is:

a) _____ Less than 50,000 b) _____ 50,000 to 149,999 c) _____ 150,000 to 249,999 d) _____ 250,000 to 349,999 e) _____ Over 350,000

3) My organization is:

a) _____ Career Fire Department b) _____ Volunteer Fire Department c) _____ Combination Career & Volunteer d) _____ Private Agency e) _____ Other

4) If there are paramedics in your department, do they work 24 hour shifts? ____ Y

____N 5) Approximately how many calls per 24 hour shift are typically worked by paramedics?

(average call volume) a) _____ 0-5 b) _____ 6-10 c) _____ 11-15 d) _____ 16-20 e) _____ Over 21 f) _____ No paramedics

6) What is the approximate average time for each call, from dispatch to completion of

reports? a) _____ 1-29 minutes b) _____ 30-39 minutes c) _____ 40-49 minutes d) _____ 50-59 minutes e) _____ Over 60 minutes


7) Indicate the EMS services provided by the fire department in your community. (check

all that apply): a) _____ BLS care with EMT’s on fire suppression units (engine or truck companies). b) _____ ALS care with Paramedics on fire suppression units (engine or truck

companies). c) _____ ALS care and transport with fire department ambulance/medic type units . d) Other _____________________________

8) The response configuration to a BLS medical call in your community most closely

resembles: (Please list the numbers of responders.) a) _____ EMT’s on a fire suppression company. b) _____ EMT’s on an ambulance for transport. c) _____ Paramedic(s) on a fire suppression company. d) _____ Paramedic(s) on an ambulance for transport. e) Other __________________________________

9) The response configuration to an ALS medical call in your community most closely

resembles: (Please list the numbers of responders.) a) _____ EMT’s on a fire suppression company. b) _____ EMT’s on an ambulance for transport. c) _____ Paramedic(s) on a fire suppression company. d) _____ Paramedic(s) on an ambulance for transport. e) Other __________________________________

10) Is there a rotation policy in your department to move paramedics from

ambulance/transport units to engine or truck companies on a routine basis? a) Yes _____ b) No _____

11) If your answer to the previous question was “Yes”, what is that rotation pattern and frequency? a) Every other 24 hour shift.______ b) Every 2-3 duty shifts. ______ c) Every 4-7 duty shifts. ______ d) Every month ______ e) Every 2-3 months ______ f) Other, Please specify _____________________________________________


12) What is the reason for rotations from medic units to fire suppression companies? a) _____ Reduce stress from high call volumes. b) _____ To catch up on training. c) _____ To balance the workload. d) _____ Personal requests. e) _____ Seniority. f) Other _______________________ Thank you again for your participation in this questionnaire.


Appendix C Fire Departments or Agencies that Participated in Both the First and Second

Research Questionnaire

1. Auburn Fire Department, Maine

2. Durham Fire Department, New Hampshire

3. Eau Claire Fire Department, Wisconsin

4. Honolulu Fire Department, Hawaii

5. Keesler AFB Fire Department, Mississippi

6. Las Cruces Fire Department, New Mexico

7. Leawood Fire Department, Kansas

8. Marysville Division of Fire, Ohio

9. Montgomery County Fire and Rescue, Maryland

10. Murray City Fire Department, Utah

11. Omaha Fire Department, Nebraska

12. Port Ludlow Fire and Rescue/Jefferson County FPD 3, Washington

13. San Francisco Fire Department, California

14. Sedgewick County Fire District #1, (Wichita), Kansas

15. Selmer Fire Department, Tennessee

16. Wilson Fire and Rescue, North Carolina

17. Union City Fire Department, California

evaluating changes in fireifhgter/paramedic staffing

Documents