(Thomas G. Daly) – In October 2015 the Washoe County District Board of Health (DBOH) released its first full year (FY2015) report on Emergency Medical Service (EMS) delivery for the County including Reno, Sparks and unincorporated Washoe County, but excluding Incline Village and the North Lake Tahoe Fire Protection District (NLTFPD), which operates its own EMS delivery and transport operation.
Background
The 2014 exclusive restated franchise agreement gives the DBOH the sole authority to exercise oversight over the Regional Emergency Medical Services Agency (REMSA), a not-for-profit group that operates ambulance service delivery (for a substantial fee to users) through its contracting arm, the Regional Ambulance Service, Inc., (RASI). A ride in a REMSA ‘bus’ will cost you about $1100 and in the CAREFLIGHT helo about $7,700. There is no competitor for REMSA and its franchise agreement has not been subject to competitive bidding since 1986.
In their Truckee Meadows service area REMSA generally responds with an ambulance (helo operations are infrequent by comparison) and a paramedic to treat those in need and does the transporting (exclusively), but a fire department unit is also dispatched.
The reason for the latter is that REMSA has so few staffed units on duty, typically 6-7 ground units and one helicopter, for a service area of about 400,000 population and 6,000 or so square miles, that their response times outside the central business districts of Reno and Sparks are far beyond the 8 minutes recommended in national (American Heart Association and National Fire Protection Association) standards. If you have a heart attack in the suburbs and had to wait for only REMSA to treat you, you would be dead and stiff before REMSA arrived.
Compare REMSA’s 6-7 ground units and one helicopter to the three Truckee Meadows area fire departments, who have 30 geographically dispersed fire stations with a significantly smaller (about 1100 square miles) service area.
Reno Fire and Sparks Fire respond with an emergency medical technician (EMT) and the TMFPD/SFPD responds with a more capable and better trained and equipped paramedic. Reno Fire runs about 26,000 EMS calls each year, Sparks Fire about 6,400 annually and TMFPD/SFPD about 6,250 medical calls per annum. EMS calls are the overwhelming majority (70%-80%) of all calls for all local fire departments. And therein is the rub.
The DBOH has approved REMSA’s ‘response zones’, so how fast an ambulance gets to you depends on where you live, not on how bad you need the service. The fastest 8 minute 59 second response zone is generally within the McCarran Loop and some northern suburbs and has been so for 20 years, despite the explosive population growth of the Truckee Meadows in the north and south valleys. If you live in the suburbs you are likely in the fifteen minute zone or, worse, the ‘best effort’ zone, also known as the ‘we will get there when we get there’ zone.
What the DBOH report does not reveal is…well…troubling. Here are some of the ‘not reported’ issues.
Fire Department personnel assisting REMSA
The DBOH staff continues to fail ascertain the number and duration of incidents when REMSA’s staffing is inadequate to fulfill their contractual obligations to provide adequate EMS to their franchise area. That data is available from REMSA’s and area jurisdictions’ emergency dispatch operations but either the DBOH staff has not requested the data or the DBOH has not directed its staff to seek it.
The use of fire department personnel to assist in the transport of REMSA’s patients results in the fire department unit being unavailable to respond until REMSA releases and/or returns the fire department staff member, per the minimum staffing requirements in those fire departments’ labor agreements. Depending on where within the REMSA franchise area that occurs and the distance to the hospital, the fire department unit could be unavailable for 60-120 minutes. Also, REMSA does not reimburse respective fire departments who assist with transport, resulting in an indirect taxpayer subsidy to REMSA.
Given REMSA’s dismal response times to areas outside of the McCarran Loop, robbing a TMFPD unit of its paramedic to accompany the REMSA unit to the hospital places TMPFD residents at jeopardy in the event of a needed additional emergency response.
The DBOH staff needs to determine how often and for what duration of time these events occur and report that data to the Board. Thereafter, DBOH members can then determine the economic and service impacts to all area fire department and citizens.
Where this situation is continuing to occur or getting more frequent, REMSA should be required to add staff, e.g., a paramedic riding with the REMSA supervisor, who would respond to all Priority 1 (critical) calls to meet this need and reimburse fire departments when they provide staff to assist REMSA with transport, reducing this taxpayer subsidy. In FY2015 Priority 1 calls accounted for 23,207 of REMSA’s 58,540 (40%) annual responses and include reports of heart attacks, stroke, serious (in REMSA’s opinion) traumatic injury or similar ‘life threatening’ events.
REMSA’s chronic under deployment of resources also results in long times for first responders (fire) to await the arrival of REMSA units, thus keeping those fire units unavailable for other calls. For areas outside of the cities’ central business districts, where fire units are plentiful, large areas of both the cities and the TMFPD/SFPD are therefore void of available fire units and any secondary response fire unit would be far beyond the 8 minute response times established by all area governing authorities and national standards.
Dispatch follies
While every study over the past 20 years of EMS services in the Truckee Meadows has said, first and foremost, ‘fix dispatch’ the DBOH report is generally silent on this issue. No dispatch reforms are suggested because REMSA is adamantly opposed to any diminution of its control of EMS dispatch.
Each EMS call now goes first to a Reno call-taker, then to REMSA dispatch and then to the respective fire department dispatch (WCSO dispatch, Reno ECOMM or Sparks dispatch), before help rolls. Dysfunctional?? You be the judge.
REMSA’s service capabilities
REMSA’s routine under deployment of resources also results in REMSA often being ‘out of ambulances’, known as ‘status six’, in the business. One only need monitor Reno’s ECOMM or the WCSO dispatch to hear such routine transmissions.
But how often and for what duration is REMSA out of ambulances? Neither the DBOH nor the public know because the DBOH staff won’t seek that data from REMSA and REMSA is not about to give it up without a specific demand, which the franchise agreement allows. As such, the DBOH members are unable to effectively evaluate REMSA’s contractual compliance with their franchise agreement.
REMSA’s dispatch clearly knows when and for how long such failures occur, but has not reported or provided the data and the DBOH staff has been a willing co-conspirator in keeping this compliance information from the DBOH and the public. As REMSA is not a ‘public agency’ they are immune from inquiries under the Nevada Public Records Act (NRS 239), so a whole host of relevant REMSA data, including compensation data, is not available to the public as it is for area fire departments.
REMSA’s franchise agreement is replete with built in ‘excuses’ (traffic, weather, etc) for longer than allowed response times to Priority 1 calls, such that their performance reports routinely results in a passing score, thus avoiding the built-in penalties in that agreement. REMSA also controls its score and contractual compliance because they control the dispatch of ambulances and can ‘adjust’ the priority of calls to avoid penalties for slow responses.
TMFPD/REMSA mutual aid agreement for ambulance service
Despite the passage of more than eleven months REMSA has yet to respond to the TMFPD’s offer of terms and conditions in the form of a mutual aid agreement, whereby TMFPD/SFPD’s sole ambulance at TM#30 Bowers (Washoe Valley) could be called upon for service in the event of a catastrophic mass casualty event or other circumstances where REMSA’s service capability is overtaxed.
Since Washoe Valley is in REMSA’s ‘best effort’ (meaning longer than 20 minutes) response zone, the TMFPD ambulance might make the difference between life and death for calls there. Nonetheless, TMFPD/SFPD is unable to use its resource to benefit citizens given REMSA’s stranglehold on transporting patients per their franchise agreement.
REMSA already has a mutual aid agreement with the NLTFPD, who also transport, so their recalcitrance in dealing with the TMFPD is clearly intentional and at odds with the direction they have received from governing authorities.
Double the cost
So area taxpayers are paying for about 75% of their fire departments’ budgets for EMS services and are additionally paying REMSA a huge fee when they transport you to the hospital. TMFPD’s direct EMS costs for FY2014 was $1.6 million.
The February 2015 county audit report on TMFPD EMS indicated REMSA had $842K more in revenue than expenses in FY2014 and its CEO earns about $400,000 in annual compensation, so why is service so poor in most of REMSA’s franchise area??? Because this supposed ‘not-for-profit’ monopolistic organization is all about profit and not all about service.
The DBOH’s management (or mismanagement) of EMS services in Washoe County is yet another reminder that a multi-jurisdictional government agency and oversight really means no one is accountable and there is no transparency.
Ask youself….is this the best service and economic model for emergency medical services for the Truckee Meadows?
Thomas G. Daly – MSc. M.A., CSP is a consultant and resident of Washoe County
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