Priority Traffic: Half MAST

Will merger with fire service destroy high-performing EMS system?

• November 2009 JEMS Vol. 34 No. 11
• 2009 Nov 1

Half MAST
In a move described as an attempt to streamline operations and save money, the Kansas City (Mo.) Council has voted to merge Metropolitan Ambulance Services Trust (MAST) directly into the city’s fire department. 

The city council voted 7-6 for the amendment, a change that’s expected to join the two within a year. "[The transition] will take us some time," says Kansas City Mayor Mark Funkhouser. "We’re going to move very methodically, and when we are ready to make significant changes, we will come back to the council with those changes."

Earlier this year, the city’s firefighter union proposed merging the two. MAST, which is a non-profit agency, receives 40% of its funding from the city. The merger is intended to preserve the highly valued medical services, while providing a potential $2 million in savings, mostly due to bringing MAST under the city’s insurance umbrella.

"There could be more changes to the service delivery model, but it will continue to provide high-quality patient care," says councilman John Sharp. "The city will have to be vigilant on how this is done to make sure that we still maintain the highest level of patient care."

Sharp has objected to the amendment, wanting the council to incorporate MAST into the city as a stand-alone department.

"I have always thought that ambulance service was just as important to public safety as police and fire service, and I wanted ambulance service to be its own department," says Sharp.

As it stands now, MAST will be a bureau within the fire department.

Darryl Coontz, interim CEO for MAST, says the merger could improve labor relations and provide stability. In the past, the ambulance service has been contracted out through MAST. "There were times when we saw a new employer every three to five years," Coontz says. "I think it’s going to be refreshing to have some stability and know that your employer has been around for 142 years and is not going to change anytime soon. There is comfort in that."

Smokey Dyer, chief of the Kansas City Fire Department, thinks the merger will be a win for residents and the employees. "I think it will be best for the community and personnel in the long run," he says. "But there’s always a lot of apprehension whenever you go through one of these changes."

David M. Williams, MS, senior consultant with Fitch & Associates LLC, says MAST is a cost-effective and high-performing service that has exceeded industry benchmarks, and he’s concerned the decision to merge was made without objective study and significant public comment or a public ballot vote. Williams worries that the community is changing an EMS system that fundamentally works, and is equal to or better than the majority of urban cities without a detailed plan in a down economy. 

"MAST has been a very transparent, high-performing, best practice system. There’s a lot of mention of performance with the merger, but I have not read any details of a plan of action," he says. "This will represent the first deconstruction of a high-performance system that works and highlights real-world concerns about city leader understanding of EMS systems and the impact of foundational changes."

Funkhouser believes the change was necessary to keep ambulance service viable in the city. "The service delivery model that we have been using was simply not going to be able to continue," he says. "The majority of employees were unhappy with their working conditions and their benefits. The collection rate had declined to around 33%, and I saw that the model we have right now couldn’t continue to provide the patient care and outcomes we wanted." 

Funkhouser also wanted Kansas City to join the large number of cities that combine ambulance and fire department service. "They will continue to deliver the same high level of service with KCFD on their sleeve as they did with MAST on their sleeve."

Williams is more cautious. "My hope is that the merger will not affect services. If previous large city EMS mergers are a prediction of KC’s future, it may see performance issues, increases in cost and EMS labor issues," he says. He cites examples like Washington, D.C.; San Francisco; New York City; and Lincoln, Neb., where EMS mergers were extremely rocky and took years to smooth out. "I expect cost control and EMS labor to remain an issue as two vastly different employment cultures meet, and EMS personnel and services work to find its place within the fire service mission."

Under the merger, one definite sticking point will be the cost of bringing current MAST employees into the city’s pension plan. Details are still being worked out, but costs to make the switch have been estimated at $17 million. 

"[MAST employees] are going to wind up with a defined benefit pension system, which they currently do not have," says Funkhouser. "They are not going to be part of the firefighter pension system, but they are going to be part of the city employee pension system."

Sharp believes that pension details will be equitably defined. "Those paramedics and EMTs have been out on the same dangerous emergency scenes as their brothers and sisters that work for the police and fire departments, and they should be given credit for those years of service," he says.

Despite the hoped-for cost savings, Funkhouser says the main objective of the merger was not based on money, but sustainability. "The objective was to move to a more sustainable system and continue with the same high level of quality care that we are currently delivering, with the same high level of citizen satisfaction," he says. "Currently, of all the services that the city provides, the fire department is perennially number one in citizen satisfaction, and the ambulance system is right behind them at number two."

As for the future, Coontz believes more and more cities will take steps to merge EMS and fire departments. "You are witnessing a shift away from non-fire based EMS to a world where the fire departments and their associated fire unions are more and more interested in acquiring this line of business," he says.

Dyer agrees. "The fire department is becoming the all-hazards organization in most cities," he says. "It doesn’t make sense to have separate fire and EMS management functions. It makes sense to have the collaboration going on somewhere else, rather than meeting up together over the patient." 

Williams has a slightly different take: "Communities will continue to reevaluate all of their public safety services, including EMS. I expect a few cities will transition their EMS operations into fire-based or hybrid fire systems over the next five years, as well as other options," he says. "The key consideration is what services need to be delivered and how they are provided, not who does it." —Cynthia Kincaid

Editor’s note: The November issue of the  EMS Insider  management newsletter will include a column by Jay Fitch of Fitch & Associates on the MAST transition. Look for it at  jems.com/emsinsider.

Controversial Study Finds Third of Prehospital Intubations Unsuccessful
A recent study evaluating trauma patients who had emergency prehospital airway management found that paramedics failed 31% of prehospital intubations (PHIs). The study, conducted at Ryder Trauma Center in Miami, tracked 1,320 emergency admissions to the Level 1 trauma center between August 2003 and June 2006. It found that of the 1,320 patients, EMS personnel had initially intubated 203 in the field, with 74 surviving to discharge. Sixty-three (31%) failed to meet successful intubation criteria. But Kathleen Schrank, MD, FACEP, FACP, professor of Medicine at the University of Miami’s Miller School of Medicine and EMS medical director for the City of Miami Fire Rescue, says these results aren’t what they seem. 

Find out why at jems.com/airway.

Pro Bono: Employer Inaction Has Steep Cost
A jury recently awarded $2.25 million to a woman who claimed a paramedic molested her in the back of an ambulance. The jury found the paramedic’s ambulance service negligent for allowing him to accompany the patient during transport, despite complaints from three other women in the two years leading up to the incident. The paramedic was ultimately charged and sentenced to five years in prison. (Read the story at jems.com.) Although this type of criminal conduct in EMS is thankfully rare, it does raise questions for managers.

What are an employer’s responsibilities when a complaint of molestation or inappropriate conduct is made against an employee? First and foremost, the employer must take all credible complaints seriously and involve law enforcement whenever the alleged conduct would, if true, constitute a criminal matter. In addition, even if a formal complaint is not made, whenever an employer knows—or should know—of conduct that may jeopardize the health, safety or well-being of patients or the public, the organization has a tort law responsibility to act reasonably to minimize or eliminate that risk. Otherwise, as this case illustrates, any third party can take action against the employer if they are harmed as a result of the conduct the agency knew of or should have been aware of. It’s never acceptable to disregard or fail to investigate a complaint about a person or a condition that could be harmful.

What about the employee? Do they have any rights when a complaint of molestation or other inappropriate conduct is made? Of course, "innocent until proven guilty" is a fundamental presumption of the American criminal justice system. However, the standard for employer action is different. Employees in an "at will" environment can be terminated, suspended or demoted for any reason, good or bad, so long as it’s not an illegal reason, such as age, race or gender discrimination. 

In public employment and where a collective bargaining agreement exists with one or more labor unions, "due process" and "just cause" standards may apply. However, in most cases, wherever a serious threat to public health or safety exists, all employers may (and in most cases, should) take prompt action to remove the threat. This means that in a case of alleged molestation, any employee (even a public or union employee) should be placed on leave or reassigned pending investigation and appropriate resolution of the matter. Courts almost always side with employers that find it necessary to take immediate action to protect the public as long as any required due process steps are followed as soon as possible after the interim adverse action is taken against the employee.

This isn’t a complete overview of all of the employment law aspects of how to handle allegations of molestation, abuse or other similar matters, and anyone who needs legal advice on such a matter should consult an attorney. However, credible complaints of such misconduct can’t be ignored, and employers face serious consequences if someone is harmed by a situation of which the employer previously knew or should have known.

Pro Bono is written by attorneys Doug Wolfberg and Steve Wirth of Page , Wolfberg & Wirth LLC , a national EMS-industry law firm. Visit the firm’s Web site at www.pwwemslaw.com for more EMS law information. 

Quick Takes
2010 Chassis Update
New diesel emissions standards that will take effect Jan. 1 have caused significant changes to ambulances to debut in 2010, and manufacturers are still making adjustments to introduce new chassis. Mercedes-Benz has formed Daimler Vans USA to take over from Dodge Mercedes and Freightliner Sprinter commercial vehicles. And over at Chevrolet, the 2010 G3500 and G4500 cutaway chassis, which were originally due to debut in accordance with the new emissions standards in January, have been delayed until late spring.

California Approves Nation’s  First TacMed Guidelines
The nation’s first statewide tactical medicine guidelines have been unanimously approved in California by the Commission on Peace Officer Standards and Training (POST) after almost two years of development. The "Tactical Medicine Operational Programs and Standardized Training Recommendations" may serve as a model to those contemplating similar programs and who need to develop core competencies and training requirements, according to Kenneth L. Whitman, POST special consultant/program manager. "With the recent deaths and injuries to SWAT personnel in Oakland, Pittsburgh and Jersey City, there is a heightened awareness of the need to establish standards for operational programs and the training of tactical medics. We believe that we have taken a giant step towards that goal," he says. Once the guidelines receive final approval by the California Office of Administrative Law, they will be available for download at http://post.ca.gov. 

$40 Million in Grants Made  to Improve 9-1-1 Services
The U.S. Department of Transportation’s National Highway Traffic Safety Administration and U.S. Department of Commerce’s National Telecommunications and Information Administration have awarded more than $40 million in grants to U.S. states and territories as part of the E-911 program. The funds will help states better track call origination from wireless and Internet-connected phones. Some 30 states and territories received grants. The largest grant ($5,390,760) went to Texas, and the smallest ($200,000) went to American Samoa. 

EMS Edutainment Coming Soon
Four University of Alabama at Birmingham (UAB) students are developing a CPR-teaching tool using the Nintendo Wii’s motion-sensing remote (Wiimote) with a grant from the American Heart Association (AHA). They’re writing code that will collect compression rate and depth information, and send it to a computer, which will analyze the data. 

With a personal computer, a small inflatable dummy, and the Wiimote, people can see if they’re performing the recommended 100 two-inch-deep compressions per minute. The UAB product is expected to be released this fall. The code will be available for download on the AHA Web site so researchers and game designers may use it in other applications. 

"There are lots of creative people out there with knowledge of technology and EMS training," said Jerry Potts, PhD, ECC director of research, development and innovation for the AHA. "It will be interesting to see what people do with [the UAB code] over time." 

Integrating training into commercial games would seem to be a slam dunk, but not all training games are created equal. Some are too basic for EMS professionals and some are too clunky for anyone (according to reviews on the Web), but very few seem to hit the right balance of learning and interesting game play.

"Zero Hour: America’s Medic," which was developed at The George Washington University (GWU) in cooperation with the Department of Homeland Security (DHS) is one such game. Gregg Lord, MS, NREMT-P, senior policy analyst at the Homeland Security Policy Institute at GWU, oversaw the development of the single-player, point-of-view game. Choosing options from drop-down menus, players assess and treat patients in various scenarios. After completing a scenario, the player has the option to take a test and earn continuing education credits (CEUs). 

Players have downloaded Zero Hour 1,600 times since its release in early summer, but few CEUs have been earned, despite the fact that players come back again and again to play the same scenarios.

"Maybe the CEUs aren’t that important" to the users, says Lord.

It may just be the people who need the CEUs don’t know about the training game. As with any product, visibility is the key to widespread use. Zero Hour hasn’t been widely marketed, and with the DHS funding recently expired, Lord doesn’t know if there will be more money for marketing the game.

You can see a demo of Zero Hour and download the game for $14.99 at http://zerohour.nemspi.org.
—AML JEMS

In Brief: CDC H1N1 Legal Preparedness Information at www2a.cdc.gov/phlp

Learn how social media can help you meet your organization’s mission at  PIOSocialMediaTraining.com

FEMA Emergency Vehicle Visibility & Conspicuity Report at www.usfa.dhs.gov/downloads/pdf/publications/fa_323.pdf

Read the LifeBot telemedicine enewsletter at www.lifebot.us.com  

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