Lights and Sirens Response with Jeff Jarvis, MD (10/12/21)

People are getting, are getting CME for this, which is always great. I know you're taking, yeah, you're taking time out of your day. I know you have your new recruits with you today, so appreciate you feeling away for 30 minutes.

So, Jeff, you're obviously very involved in EMS as a frontline medical director in Williamson county, near Austin, and you're obviously very involved in research. And one of the big reasons that we wanted to bring you back is because the research that you've done in the past is now becoming a springboard for something really larger moving ahead into the future. So we'd love to hear from you and thanks for coming on. Ladies and gentlemen, Dr. Jeff Jarvis. Welcome.

Well, seriously, Peter, I really appreciate the offer. So we did a paper a while back and to give you some ideas, this is a paper we did on whether we can reduce the use of red lights and sirens going to 911 calls. So I think, like most of y', all, this has been a bit of an irritant to me because I think we have realized once we get past the, wow, it's really cool to drive red lights and sirens to calls, what we realize is, yeah, it may be sort of cool, but it's also dangerous. This is how EMTs and paramedics get hurt. And I don't think any of us want that. As medical directors and as leaders in our organization, all of us recognize our primary responsibility. Responsibility is to make sure that our medics get to go home at the end of their shift. And one of the best ways we can do that is make sure they don't get killed while they're doing their job. Red lights and sirens increases the likelihood of that. Now, that might be worth it if using red lights and sirens made a clinical difference. I think all of us have been a bit frustrated from time to time at arbitrary response time requirements where we have to throw resources at getting to low acuity calls within an arbitrary number.

So what we were coming up with is we wanted to get an idea, an assessment of how often we do something clinically relevant when we're running lights and sirens. And we wanted to do it in a way that presented a methodology that we could use locally to try to decrease our red light and sirens use in a meaningful way based on our data. So where this idea came from, I was actually out at one of my EMS systems at Marble Falls and I was talking to a group of new hires and the question came up, well, how do we know when we need to use red lights and sirens and Not. And I said, wow, this sounds like a great research question. So Vaughn Hamilton, who is one of the training officers there at Marble Falls.

Said he suggested, well, why don't we use the ESO data set to try to answer this question.

So I said, that's a great idea. Vaughn, you're on the paper with me. Let's get two other people who both know about quality improvement and about research. I asked Lawrence Brown, who is a researcher at University of Texas at Austin, just down mysouth, who has also done a lot of work both with the ESO data set, but also on this notion of red lights and sirens. He and one of his colleagues down there in Austin, Dr. Watanabe, is just recently published a paper looking at the impact red lights and sirens has on accidents. And as we would suspect, they were able to document that there was an increased number of accidents using red lights and sirens. And then we also asked Mike Tagman to join. So that was the four of us who are working on this paper. Those are my co authors. And what we wanted to see is of all calls that responded lights and sirens to the scene, we wanted to find out how often they actually did something clinically relevant. And sorry about this, I just have a brand new microphone stuck to my computer and it seems to be wobbling. I think it's not terribly excited about this conference call, which is deeply disappointing to me. So hopefully it's not going to fall off in the middle of our discussion. So the idea is we looked at all red lights and sirens calls and we tried to find out how often there was something potentially life saving. Now the way we define that was essentially a consensus based process. The four authors took a look at every intervention that was listed in the ESO data set and we were using the.

2018 Public ESO Research data set. So we looked at that, looked at every intervention, every treatment, every type of pre hospital alert and we made a list and we sent it out to the authors and each one of us ranked these things as potentially life saving or not. And then we did a consensus panel to agree on a final list. So we came up with that list and then we said, how often do we do one of those things at any time in the call when we go lights and sirens? So what we found just overall, the Data set had seven and a half million records, 5.9 million of those were red lights or I'm sorry, were 911 calls. 86% of those involved a lights and sirens response to the scene. So, so 86% of the time we're going lights and sirens to the scene. We had to exclude some of these calls. 987,000 of them had no patient contact. So obviously we're not going to do an intervention when there's no patient. And 483 of them had no call determinant listed. So we didn't know what the call nature was. That left us with a final analysis set of 3.8 million calls from just under 1200 different EMS agencies. And overall we found 6.9% of those calls that we responded lights and sirens to actually had any potentially life saving intervention. And we were unbelievably conservative with our definition of a potentially life saving intervention. We then broke this down by call determinant and we said what? For each call determinant, how often did we do life saving things? And only 25% of all of the call determinants had life saving interventions done more than 10% of the time. So we looked at 10% just as an arbitrary threshold. Everybody can pick their own threshold, but we picked that and we found only 25% of those calls had that threshold. Now, if we were to say, let's take this methodology and look at our individual agencies and this is a process we're doing right now. We're getting all of our stakeholders together, including politicians who have to take heat from the citizens when the ambulance doesn't show up lights and sirens to their stubbed toe. So we want all of them to understand this and that group of stakeholders is going to look at all of the interventions that are possible and help us come up with our list so they'll have some ownership into it. The next thing we're going to do is ask them what threshold should we use to make our red lights and sirens determination? At what point, if there is a 50% probability of US doing life saving stuff, do you think we should go? How about 25%, 10%, 5%? I don't think there is a certainly there's no literature based answer to this and I think it has to be a value judgment based on the stakeholders weighing the risk of lights and sirens versus the potential benefit. But if you were to come up with say a 10% threshold and we were to apply a 10% threshold in this group, we would decrease the use of red lights and sirens to the scene by 47%. If you were to use a 5% cutoff on this data set, it would result in a 67% reduction in lights and sirens. Now, I don't know what the right percent of Your calls we should run. I can tell you that looking at the ESO data set and looking at the NEMSIS Data set, overall, 80% or 87% of all of our 911 calls respond with lights and sirens. My gut tells me that is too high on an order of magnitude. So particularly if we're only doing something that by anybody's description could be lights and sirens 7% of the time. So it should be less. Again, not sure what the, the actual cutoff should be, but I think we can all say it should be much less than 87%. Now, I will tell you as foreshadowing, we have a national quality improvement effort that we are trying to kick off right now that will look at reducing red lights and sirens risk. I am involved with it from NEMsqua, the National EMS Quality Alliance. And one of our performance measures is exactly this. It's the proportion of calls, 911 calls that you respond to without lights and sirens. So that's the measure that we're going to try to improve nationally. I'm not sure what methodology we're going to ultimately end up with, but I think we have described in this paper one methodology to use. There are probably multiple ways to get there, but this is one that we're going to try to use locally. So, Peter, I think that is the gist of what we did. I am happy to answer any questions or.

I'd love to hear some discussion about this. I think it's an important topic.

Yeah. Now this is a great topic for me. My first year as a medical Director Back in 2010, one of my best medics was in the back of what we call him Rescue 1, back of our rescue. And he had a guy who had an allergic reaction, but, I mean, only needed Benadryl. I mean, this guy was not an ALS patient by any stretch of imagination. And of course they were screaming down the street, lights and sirens, and they got broadsided by one of those tow trucks that, that carries 18 wheelers. Like, you know, it's a big, the big guy, right? And thankfully it was one of our new boxes that was.

Double reinforced, whatever. And he only broke several bones of his back. Okay. He didn't die.

That was the last day of work he ever had. And he had many, many issues following that.

From that day forward, I kept saying to myself, why are we doing this? And I would love to hear from other folks on the call. And you have people here from all over the state leaders from all over the state and from the state office as well, and I'm curious as to, you know, you have numbers here that are extremely high, 86% of calls. And why. Why can't we reduce that? And why haven't we reduced it yet? And I love where you're going with this as far as making it a, you know, a KPI, if you will. But we have a lot of great EMS leaders on this call.

Hey, Peter, I'm wondering, you mentioned state officials. Do we have the National Medical Director of the Year on this call?

Let's see. Is Shepkey on this call? Did Ken come on today?

You know what? I just spoke to him. I'm surprised he's not on. But he's not on the call.

Well, if he's not, you know, as a Texan, I don't get to talk to Floridians every day. So congratulations to. To Ken and to your state.

Listen, and Ken's an amazing guy. Thank you for that. I'll pass on the message. And we have to thank Dr. Pepe for nominating him. So Paul's on the call as well. I would love to hear from David Hudak or let's see who else was on here. John McPherson, Chief Dominguez, you guys have been in this for a long, long time. Tell us how we can fix this problem and what you think about Jeff's concepts here. Sam, Anthony, unmute yourselves. I want to hear from the EMS side of the world as to what the issue is here in Florida like it is across the country.

Kim, go ahead. Dr. Landry.

Hey.

Well, good morning, everyone.

You know, I have. I respond to a lot of calls with my crews, and I have come to realize that experience is a determining factor in how they respond to the hospital or not. I find that a lot of the younger paramedics that have less experience have a tendency to light it up and get to the hospital with a patient that I was on scene with them, and patient is quite stable. There really is nothing urgent that would require lights and sirens. But in the minds of the medic, when I talk with them afterwards, it's the anticipation that something might go wrong, and they want to just get to the hospital before that might go wrong happen. So I think the younger, the less experienced the paramedic, the more tendency they have to want to respond with lights and sirens.

Man, I think you are spot on. Just looking back at my own career as a paramedic, I did exactly that. And I think we also under, or overestimate, I should say, as paramedics, how likely it is that something is going to be done important in the emergency department and as emergency docs, we recognize. Look, if I actually get in the room with you in the next hour, you should be lucky things don't happen really, really rapidly. And when they do, it's for airway management. Okay, well, EMS almost always can take care of that. It's for cardiac arrest, which, you know, we can take care of most of the things that would require us as physicians in the room on arrival. EMS can take care of. So there are very few things that would justify the use of red lights and sirens. And we did our research based on seen responses. People have already done the exact same thing on responses to the hospital. And what they found is very rarely. Just, I mean, basically what all of us know, very rarely do things get done. So that anticipation that you're talking about is very real. And I think you're absolutely right. It's an experience based thing.

Angus, did you want to make a comment that. I saw Jim put his hand up.

As well.

So I guess I can. I think part of this has to do with aligning incentives. So, you know, we have this historic thing about a response time as a metric that indicates performance level and many, many, many folks have contracts or agreements that are written to those. Sometimes it's even in statute. So I think this is good work towards making those things be a little bit more evidence driven and maybe readjusting what the expectations are. But certainly there's a lot of people who, you know, money's on the line for making that response time.

Absolutely. And if we can convince Domino's Pizza to get rid of it, hopefully we can convince our legislatures and our payers to get rid of it.

Good one.

Let's see. Jim, did you want to make a comment?

Yeah, I did. I've been involved in this an awful long time and I think when you make it a sort of a, you know, if either or decision, it becomes problematic because either you get there fast or you get there really, really slow in times of traffic. And I think from a, from a. Again, I agree with your study and I think it's well done and I think red lights and sirens is dramatically overused. But the alternative is just go with the flow of the traffic in some cases means an unacceptably long wait for the person who styled 911 clinically, probably not going to make any difference, but they're just not willing and interested in waiting that long. The reason that I mention it is because there might be an opportunity. I just got off the phone call Here in Pinellas county, with some of the new technology that's out there.

That allows the emergency services to interact with the flow of traffic in the traffic system. It's not a get there in four minutes or get there in 25 minutes, perhaps like the bus systems are doing, regulating the flow. So it's not such a dramatic difference between red lights and sirens and non red light get there in a more reasonable period. So if I were a responder and knew I was going on a stub toe and I knew it was going to take me 30 minutes to get there, non red lights and sirens, I light it up and I get there. But if I knew like a bus, that it's going to be relatively shortly, short time till I got there, if I'm going to get there in 8, 9, 10 minutes, because I can regulate the control of traffic to get there. So If I'm on US 19 and there's a three mile backup, I can clear the traffic without use of red lights and sirens before not having to light up. There's some technology that's being used.

Several areas throughout the country that allows sort of a an urgent but not, not an emergent response occurring. And we're looking at that. Again, it's not a solution, but it might be part of the solution to changing the mindset. It's either get there in four minutes or it's going to take you 40 minutes to get there. Those two extremes probably need, need to be bartered in the middle.

You know, if you look at just traffic safety in general, our highway departments deal with things like this all the time. We're seeing new intersections that are coming in here. For all I know, the rest of the country already has these things, but they looked at their data and realized a lot of the serious injuries at intersections come because of, you know, t bone collisions. So they just changed the roads so that t bone collisions are much less likely. And so using engineering to decrease the likelihood of a collision or decrease the like or the need for red lights and sirens I think is absolutely part of the solution. Things like opticons or things, you know, changing the road systems, however you do it. There are lots of smart engineers out there, but I think there are a lot of ways to do it and make this safer. Great point.

Now, Jim, thank you for the question. Anthony, you're up.

Yeah, I think that to be honest with you, there are some baby steps with this and I think that our protocols have a lot to do with this. Priority dispatch, I think was really key in helping us as A whole get to the concept of, okay, this is what a non emergency is and this is what an emergency is.

Right.

So I really think that we need to address this from the beginning, you know, in establishing what exactly is an emergency from Priority Dispatch, I think Dr. Jameson has done a really good job with our protocols and helping us understand, you know, what's, what's an emergency, what's not. And then also, we don't run emergency to the hospital very often anymore. We had to realign our thinking. Even with strokes, if you think about it, one minute we're going non emergency with strokes, and all of a sudden now it's an emergency, oh my God, we got to get to the hospital and now we're okay. Well, is it a bleed or is it a bleed? Things along those lines. So some things can become a little convoluted. One time, one minute we're saying one thing that is an emergency and another time we're saying that it is not, if that makes any sense. I think overall we've done a better job with Priority dispatch. I believe we need to tackle this more from the beginning of the call and really establishing what are we really going on. And I think if we do that, we might even be able to figure out better where we can bring the person, because I don't believe everyone needs to go to the hospital. I don't. I believe we can, we can, we can sparse this out a little bit. So that's my two cents.

I apologize.

Great comment, great comment. And Joseph Zalkin just commented about a paper and by Hinchy and Myers and so forth. Joseph, you want to give us a blurb on that?

It's ancient research today. It would be a whole lot easier today with the electronic records than the manual sorts we had to go through. But the focus was, can alpha calls under EMD be safely responded to without lights and siren, and what were the patient outcomes? So not only the dispatch side, but the final dispatch to discharge what was the discharge of those patients? This needs to be repeated. I think I would encourage a reason. I don't know if we have any researchers on the call, but I think it's worth doing again. And I wholeheartedly agree. I think our numbers are about 14% cold response on the outbound. We didn't look at transport from scene to hospital, but now with the ability to do that rapidly, I think that should make an impact on what we train and how we operate.

Great, great comment, Joseph. Thank you and always thank you for joining us. I'm putting up on the screen here. So this is from one of my systems here in Florida, South Florida. So if you're an eso, you can just look at the report. And again, Jeff, just so you know, most of us down here in the south part, I don't know about the rest of the state use eso, but whatever EPCR you're using heartily agree.

I think our numbers are about 14% cold response on the outbound. We didn't look at transport from scene to hospital, but now with the ability to do that rapidly, I think that should make an impact on what we train and how we operate.

Great, great comment, Joseph. Thank you and always thank you for joining us. You should be able to go and get your report. So Jeff, you want to make any final comments on that part of it and then we're at the bottom of the hour, so I'll give you the final word.

Yeah, absolutely. And Peter, if you'll bring that back up again, I think I'm really glad you did that. So I'm going to put my nemsqua hat on here.

I. I'm putting up on the screen here. So this is from one of my.

Systems here where we deal with measures all the time. And as a matter of fact, we just are final in Florida, South Florida.

So if you're an eso, you can just look up the report. And again, Jeff, just so you know, most of us down here in the south part, I don't know about the rest of the state use eso, but whatever EPCR you're using, analyzing a contract.

With Florida on these fare measures where we developed a lot of performance measures. Performance measures are only useful for an organization if they can easily see how they're performing on them. Platforms like ESO are making that easier. You're looking at a great demonstration of this right here.

You should be able to go and get your report. So Jeff, you want to, you want to make any final comments on that part of it? And then we're at the bottom of the hour, so I'll give you the final word.

Yeah, absolutely. And Peter, if you'll bring that back up again, I think I'm really glad you did that. So I'm going to put my nemsqua hat on here where you can actually see how you're performing on this measure. I see over Dr. Jameson's shoulder. First Watch gauges. First Watch also does this with other platforms so they can integrate these measures in and make them really easy for you to see where you're progressing. Where we deal with Measures all the time. And as a matter of fact, we just are finalizing a contract with Florida on these fare measures, where we developed a lot of performance measures. Performance measures are only useful for an organization if they can easily see how they're performing on them. Platforms like eso. First Pass now does it with control charts so you can see your performance really, really well. The one thing I would urge you to do is make sure you're familiar with what the measure is. This measure, for example, is, I believe, with eso, it's actually the inverse of the NIMS score measure with NIM are making that easier. You're looking at a great demonstration of this right here where you can actually see how you're performing on this measure. I see over Dr. Jamison's shoulder. First Watch gauges. First Watch also does this with other platforms so they can integrate these. We wanted to make a higher number be better, so we inverted it so it's the proportion of.

Responses without lights and sirens, which, when you think about it, just seems kind of weird. But we did that to get the number, a positive number being better. So make sure you understand what the data measures in and make them really easy for you to see where you're progressing. First Pass now does it with control charts so you can see your performance really, really well. The one thing I would urge you to do is make sure you're familiar with what the measure is. This measure, for example, is, I believe, is when you're getting it from a vendor.

Well, that's perfect. And listen, there's no doubt in my mind, and I'll say it every time I can. There's no other medical director in the state that has his numbers more down pat than Angus. He's got like, you know, he knows when someone, you know, farts, it comes up on a gauge somewhere.

With eso, it's actually the inverse of the nemscore measure. With nemscore, we wanted to make a higher number be better, so we inverted it so it's the proportion of.

Responses without lights and sirens, which, when you think about it, just seems kind of weird. But we did that.

Hey, Peter. Peter.

Yes. We're about to end. Can you hear me?

I just want to make sure Everybody has the one three zero. What is it? One five today? 1305.

Yeah.

Correct.

Yeah.

Yep.

I had it up to get the number. A positive number being better. So make sure you understand what the data is when you're getting it from a vendor.

Well, that's perfect. And listen, there. There's no doubt in My mind and I'll say it on every time I can. There's no other medical director in the state that has his numbers more down pat than Angus. He is on the screen. I'll do it one more time before we go.

As a caveat here.

Yeah. And I just wanted to have one caveat. When I looked at this back in the. With a lot of runs that I was examining, like close to several hundred thousand over a several year period. We looked at the, the events that happened with the car.

He's got like, you know, he knows when someone, you know, farts it comes up on a gauge somewhere.

Oh boy.

Incredible.

Hey, Peter. Oh, yeah, Peter.

Yeah, we're about to end.

Yeah.

Can you hear me?

I just want to make sure we have. Yeah, Everybody has the 13 0. What is it, 15 today, Rex, or you know, whatever else, you know, collisions. One of the things we found, we actually were able to go back and look at this closely was that actually people had poor driving records. People had the problems that poor driving records in a sense in their private lives as well. So it, so there that. The other thing is to make sure as you do this, it's not every. It's maybe again a small group of people that are accountable for a lot of the 1305 for the CME. Correct.

Yeah. Yep. I have it up on the screen. I'll do it one more time before we go.

As a caveat here is that I.

Yeah.

I just wanted to have one caveat. When I looked at problems that we see and it may have been predictable to some extent, it's very hard to do that. But it's just something to throw in there. Just keep that in the back of your mind. Okay. That, that thing as well. Okay.

Which is, Paul, is a great comment. That's probably why at least in my.

Department, this back in the. With a lot of runs that I was examining, like close to several hundred thousand over a several year period, we looked at the, the events that happened with carbon.

You're not getting hired if you have any traffic issues on your record. You're like completely cut out.

You'd be the best. Or, or you create a culture where everybody's part of it. Wrecks or, you know, whatever else, you know, collisions. One of the things we found, we actually were able to go back and look at this closely was that actually people had poor driving records. People had the problems that poor driving records in a sense in their private and, and keeping each other honest on this stuff. So. Okay, that's all right.

Awesome. All right, Jeff, give us the last word. Take us away. Give us the last pearl of wisdom. And again, thank you for coming on today.

Yeah. Great job, Jeff. Thank you so much.

Thanks, Peter. Thanks, Paul. I guess the last thing I would say is, as an Aggie, I am damn proud of my Aggies as we defeated Alabama.

As well. So it. So there. That. The other thing is to make sure as you do this.

It's maybe, again, a small group of people that are accountable for a lot of the problems that we see. And it may have been predictable to some extent. It's very hard to do that, but it's just something to throw in there. Just keep that in the back of your mind. Okay. That. That thing as well. Okay.

Hey, Nick Saban, we appreciate you, man. Thank you so much.

There are a lot of T shirts around College Station right now that say, not today, Saban.

Great job. Congrats on that win. And again, Jeff, thanks for Aggie jokes.

Now for a while.

All right, take care, guys. Thanks a lot.

Which is, Paul is a great comment. That's probably why, at least in my departments, you're not getting hired if you have any traffic issues on your record.

Yeah.

You're, like, completely cut out. Be the best.

Or. Or you create a culture where everybody's part of it.

Yeah. Thank you. All right, now on to the big show, Dr. Pepe and.

And keeping each other honest on this stuff. So. Okay. That's all right.

Awesome. All right, Jeff, give us the last word. Take us away. Give us the last pearl of wisdom. And again, thank you for coming on today.

Yeah. Great job, Jeff. Thank you so much.

Thanks, Peter. Thanks, Paul. I guess the last thing I would say is, as an Aggie, I am damn proud of my Aggies as we defeated Alabama.

People who hate Nick Saban. Yeah, people hate Nick Saban. We appreciate you, man. Thank you so much.

There are a lot of T shirts around College Station right now that say, not today, Saban.

Great job. Congrats on that win. And again, Jeff, thank you.

Jokes now for a while.

All right, take care, guys. Thanks a lot.

See you, Jeff. Thank you. All right, now on to the big show. Dr. Pepe, what.