Saturday, June 19, 2004

City rescue squads strained

Resources lag number of calls

By Jane Prendergast
The Cincinnati Enquirer

Cincinnati firefighters Kenyatta Smith (left) and James Morgan unload a patient from Ambulance 29 this week at Good Samaritan Hospital. The young woman was experiencing general weakness at the Millennium Hotel, downtown.
The Cincinnati Enquirer/GLENN HARTONG
Cincinnati, struggling to figure out how to respond to more ambulance calls with less money, already lags behind many other cities in the number of ambulances per resident.

The Cincinnati Fire Department operates 10 ambulances from firehouses in the city - one for every 31,128 residents. And a growing number of calls seeking medical care made them unavailable last year an average of 11/2 times every day.

No one in Cincinnati's fire department, firefighters' union or at City Hall is surprised by the shortage. For years, firefighters have complained about too many calls for medical help and too few people to handle them effectively.

The issue arose again after a June 6 tour bus accident in which 22 people were hurt and not enough city ambulances were available to take them to area hospitals. The district fire chief in charge of the crash initially had four of the city's 10 ambulances. The remainder were busy crisscrossing the city answering other calls for medical help, so the chief got ambulances from Woodlawn and Golf Manor to help.

Investigators continue working to determine why the bus stalled and the driver couldn't brake. City Council's Law & Public Safety committee plans to talk Tuesday about hiring a consultant.

Ambulances crisscross the city (PDF file)
The consultant would take a broad look at fire department operations, including how it provides emergency medical care and whether the city has enough ambulances.

"Clearly, we need to get our arms around this,'' said Councilman David Pepper, chairman of the law committee. His staff informally surveyed a dozen or so cities across the country, finding Cincinnati comes up short. "This is just not acceptable.''

Doing more with less

Cincinnati has fewer ambulances per resident than Columbus, Lexington and Dayton, Ohio. Even smaller suburbs such as Colerain Township and Florence have more ambulances per person. .

Cincinnati ambulances got 50,000 calls last year and transported patients to hospitals in a little more than half of those cases. Ambulances were unavailable in the city 574 times last year.

But facing a predicted budget shortfall of as much as $71 million by 2008, city officials aren't sure how to fix it.

"The sad part is that when something's been broken for so long, it becomes policy. It becomes expected,'' fire District Chief Denny Clark, EMS supervisor, said.

Experts say there's no clear standard on how many ambulances a community should have. The American Ambulance Association recommends at least one ambulance for every 25,000 people.

John Sinclair, chairman of the International Association of Fire Chiefs' EMS committee, said the number should depend more on a city's demographics and geography than its population.

Cities in Florida need more ambulances because many residents are older, he said. Statistics show people 65 and over use emergency medical service four times as much as younger people.

Like many cities, Cincinnati is at a crucial time in this debate, Sinclair said: "There needs to be a decision. Are you going to allow this to occur?''

No easy fix

Fixing the problem is more complex than limiting the kinds of calls - such as menstrual cramps and cut fingers - that Cincinnati's trained emergency medical workers currently respond to.

"I don't think that an expert exists,'' Sinclair said. "I think there's a whole lot of people trying to figure it out.''

Cincinnati tried to cut down unnecessary runs by spelling out exactly when a person should be taken to the hospital. But after a two-month pilot project earlier this year, the city discovered it was taking more people to hospitals than before. The project was scrapped in favor of waiting for the consultant's recommendations.

City Manager Valerie Lemmie, after riding with an ambulance crew in the fall of 2002 and seeing many less-than-emergency runs, suggested a public education campaign that would include TV and radio advertising spots.

But Sinclair said similar programs, including "Make the Right Call'' in Washington, D.C., 10 years ago, spread the word about calling 911 and increased the number of emergency calls.

More problematic are the needs of the aging population and rising health-care costs, he said.

Fire Chief Bruce Smith in Colerain Township, the second-busiest department in Hamilton County and the largest township in area and population in Ohio, has seen an increase, too. But he says those are tied to growth in the region and an aging population. The department makes more than 5,000 medical runs a year with four ambulances and soon will discuss how to add a fifth.

"As we grow older, health problems increase,'' Smith said. "People legitimately need these services. It's a squeeze for us.''

And there's little financial relief for cities and townships, which bear the burden of paying for ambulance services.

Communities aren't being repaid for many of the ambulance services they provide; many of the patients come from poorer, urban neighborhoods and can't afford to pay. Health insurers also have cut reimbursements for ambulance rides.

Ideas elsewhere

Cincinnati isn't alone. Cities across the nation are struggling with similar issues and are coming up with differing approaches to ease taxed systems.

Sinclair said an idea percolating in the emergency services field is to use retired nurses and schoolteachers to visit repeat 911 callers at their homes to find out why they're calling so much. A lot of people call 911 because they don't understand a new diagnosis or the side effects of new medication, he said. Targeting those people should work better than broader, more general public education efforts, he said. Officials said calling an ambulance should be reserved for potential life-threatening emergencies.

Several cities across the country, including San Francisco, issue taxi vouchers to people who want to go to a hospital but don't really have an emergency. A program in Lakewood, Wash., just south of Tacoma, won an award from the chiefs association last year for taking the voucher idea a step further - getting a charity to pay the average $11 taxi fare. The rides, which started in 2000, saved the city more than $26,000 in its first year.

Cincinnati's busiest ambulance, housed in the West End, gets calls for help every 87 minutes. That's too often to assess a patient, get them to the hospital and then complete the necessary paperwork - all of which can take an hour, officials say.

Clark characterized the members of his department as desperate to get the fire administration, which includes him, to do something about the workload. Busy days leave little room for eating or resting, which he said prompts concern for both the medical crew members, who get tired doing back-to-back transports for 24 hours, and for the patients.

"What we're looking at now is what is a safe number of calls to go on in a 24-hour period - and 18-20 calls is too many,'' he said. "The bottom line is we don't have the tools to do the job, and we haven't for a long time.''


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