A Blueprint To Increasing EMS Service Levels

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Perseverance and persistence do pay off. Just ask the fire chief and firefighters of Cuyahoga Falls, OH, who saw a need to increase EMS service levels to their citizens - and did something about it.

It all began in May 1998, when the mayor formed a committee to discuss EMS transport issues and report its findings to the city's EMS Commission. The main issue was whether the Cuyahoga Falls Fire Department should retain American Medical Response (AMR) as transport provider or begin to transport patients itself. Using a report prepared by certified public accountants, the committee explored four possibilities:

  • Allow the Cuyahoga Falls Fire Department to transport all patients.
  • Allow the Cuyahoga Falls Fire Department to transport only patients requiring advanced life support care.
  • Continue with a non-transport policy.
  • Collaborate with private ambulance companies for a portion of the fees.

The debate pitted the fire department against AMR. The department argued that it could provide a better continuity of care and quality of care to the community, while AMR contended that there was nothing wrong with the system and that 93% of its responses come in nine minutes or less. Further, AMR questioned the fire department's ability to take over patient transport with the current number of personnel and anticipated cost of running the system.

Of course, it was in AMR's best interest to keep the system in place. Cuyahoga Falls was typical of a public/private cooperative in which the fire service does first response and specialized rescue while the private company does the transport. Under a public/private cooperative, only the transport agency is reimbursed by Medicare, Medicaid or private insurance. Further, it is illegal to "kick back" federal money to another agency on specific calls. Therefore, the vast majority of fire departments doing first response in this country receive no reimbursement for those services. Can you name any other government agency which supplies materials and human resources to help a private contractor make a profit?

What a sweet deal! The fire service bears the cost and responsibility of maintaining response times to provide advanced or basic life support usually within four to six minutes, provides any specialized rescue needed, and sometimes sends a paramedic/firefighter in the back of the private ambulance as third person with a critical or serious patient. But then the private ambulance provider walks away with the money.

Citizens of Cuyahoga Falls said they were not pleased with the public/private arrangement. In September 1998, about 100 people showed up to express their opinions to the EMS Committee. One resident expressed frustration when he was charged what he considered an exorbitant fee for transport. He further elaborated that he "could throw a rock from my house to the hospital." Another citizen said, "I feel that we have the best fire department in the nation. They have always been there when we needed them and if they feel they can do the job, I'm behind them 100%. Anything we can do keep the money in this city, I think we should do."

After several presentations from AMR and the Cuyahoga Falls Fire Department, the EMS Committee said it saw advantages to the fire service providing EMS transport. In September 1998, a motion was made to recommend to the mayor that the fire department take over patient transport for all calls and begin charging residents and non-residents for the service. All the members of the committee voted in favor of the motion except the AMR representative and the International Association of Fire Fighters (IAFF) union president, who abstained. Steve Durkit, president of IAFF Local 494, abstained since he had not had an opportunity to let his membership vote on the transport issue. But the opinion of the firefighters did not take long. On Sept. 4, 1998, the union membership voted unanimously in favor of a fire-based transport system for the city of Cuyahoga Falls.

In late September 1998, the EMS Commission recommended that the fire department experiment with transporting patients to the hospital. With the recommendations and support of the committee, the EMS Commission and the firefighter local, on Oct. 15, 1998, the mayor gave his blessing for the fire department to begin a trial EMS transport on Dec. 1.

Under the new system, there would now be continuity of care, instead of the old system of transferring the patient from one crew to another.

Responding to the mayor's decision, Cuyahoga Falls Fire Chief Mark Snyder said, "We'll eliminate the one question from residents that has haunted me for years: Why don't you just take me?"

After learning of the mayor's decision, AMR Regional CEO Greg Lawton indicated that AMR would leave town after the fire department transport system became operational.

With the start date just around the corner, Snyder and his department had to make all the necessary preparations for a successful program. Apparently their hard work paid off. During the debate, opponents of a fire-based system had argued that the department would not have the personnel to transport, that EMS mutual aid would be necessary and that fire suppression would suffer. But, according to Snyder, all proved wrong. During the month-long trial period, the department never called for EMS mutual aid , and the number of personnel was not compromised during several fires. In the first month of operation, 270 patients were transported by the fire department and several fires were handled without complications. On Jan. 25, 1999, the City Council voted to authorize the fire department to start billing for transport services.

One year later, the report card is in. With an average response time of four minutes, the program has increased personnel from 80 to 84 and decreased time from dispatch to enroute to the hospital from 30 minutes to 19 minutes. Additionally, anticipated revenues will top $1 million for 1999.

Without question, the move to increase service levels to the citizens of Cuyahoga Falls has proven to be an unqualified success - thanks to the members of the Cuyahoga Falls Fire Department. A tip of the helmet to Snyder and the personnel in his department.


Gary Ludwig, MS, EMT-P, a Firehouse® contributing editor, is the chief paramedic for the St. Louis Fire Department and is the vice chairman of the EMS Executive Board for the International Association of Fire Chiefs. He has lectured nationally and internationally on fire-based EMS topics and operates The Ludwig Group, a consulting firm specializing in EMS and fire issues. He can be reached at GaryLudwig@aol.com.

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