MARIANA ALEXANDER: ‘Surprised’ by imbalance.

City fire unions sharply criticized a conservative think tank’s claim that the city should close firehouses and use the savings to upgrade ambulance services, saying such a move would cost lives.

The Emergency Medical Service is inefficient and shortchanges responses to life-threatening calls because it dedicates an “excessive share of resources” responding “to noncritical incidents,” according to a recent report from the Citizens Budget Commission, a business-funded fiscal watchdog.

The CBC was particularly critical of the Fire Department's current protocol of sending a crew of firefighters and an EMS unit to the scene of some calls for medical aid, which the department maintains ensures the fastest response times.

Too Much ‘Fire’ Power?

According to the FDNY, an engine crew is dispatched only for life-threatening medical calls—roughly 1 in 5 of the 1.5 million EMS runs.

“The use of fire engines in addition to ambulances to respond to medical incidents is wasteful,” according to the CBC. “Heavily staffed fire engines are far more expensive than ambulances: In 2017, the estimated average cost of a fire engine response to a medical incident was $1,970, while the average cost of an ambulance run was $486.”

The CBC stated that medical incidents comprise more than 80 percent of the calls to which the FDNY responds, while less than three percent of responses are to fires. In 2017, fire companies also had to respond to 242,545 non-fire, non-medical incidents such as gas leaks, along with 45,476 fires.

Abused Patients

According to the CBC, research indicated a significant number of FDNY EMS runs were being made “when professional medical care is not actually needed; when the sick person could have gotten to the hospital or to another medical care provider safely on his or her own; or when the situation could have been avoided with earlier care or behavior change.”

The report stated, “Prior estimates of inappropriate use, defined as calls when professional medical care is not needed, range between 11 percent and 16 percent of incidents. Research also suggests that inappropriate use is more prevalent among Medicare and Medicaid patients, possibly because those patients are less likely to have regular medical care or alternative means of transport, and because Medicaid patients do not bear the cost of the ambulance ride because there are no copays.”

The CBC analysis continued, “Avoidable use—ambulance use for chronic conditions like diabetes, asthma, or addiction—is particularly pervasive and costly, and for many of these patients, the ER is not the ideal treatment site. In addition there is evidence that a subset of patients with chronic conditions, called “frequent fliers,” are prone to recurrent EMS use, relying on ambulances and ERs for routine care.”

In a statement, the FDNY said officials shared “the CBC’s concern about unnecessary or inappropriate requests for ambulances—and have been working closely with NYC H&H, Greater NY Hospitals Assn. and the city health care networks that are participating in the Medicaid DSRIP program to ID appropriate alternative pathways for these patients to receive care.”

Structural Imbalance?

“What I was surprised by from the data was that medical responses make up 83.5 percent of the FDNY’s call volume but account for only 28 percent of the FDNY’s total budget even granting that EMS services are less expensive than fire extinguishment and suppression,” said Mariana Alexander, a CBC research associate, who authored the report.

The CBC maintained that the system was not just inefficient but less than medically effective because when firefighters arrive at the scene of a medical emergency, the actual aid they provide is of a “limited nature.”

“In 2017 when a fire engine responded to a medical incident, patient care was provided in only 2.0 percent of incidents, while assistance is labeled as ‘action taken, other’ for 97.0 percent,” the CBC reports. “Astonishingly, out of the 281,000 fire engine company runs, in only 72 instances (0.04 percent) was a defibrillator used. The reliance on first responders who cannot transport also ignores research suggesting that for many critical incidents, particularly acute trauma, what matters most is not how quickly staff arrives at the scene, but how quickly the patient is transported to an ER.”

CBC contended that when it comes to responding to the most serious medical calls, the city has been losing ground in recent years.

Too Slow on Responses

“The City is falling short of a National Fire Protection Association benchmark that response to an incident requiring Advance Life Support care should be by an ALS ambulance within 9 minutes at least 90 percent of the time,” according to the study. “The FDNY historically has held itself to a lower standard of ALS response of 10 minutes 90 percent of the time; according to the FDNY, in 2017 only 57.6 percent of ALS responses to ALS incidents met that benchmark. In fiscal year 2011 this figure was significantly better at 80.5 percent.”

The think tank called for the city to identify firehouses that could be closed, with the savings used to increase EMS staff.

“Such an assessment should identify where companies could safely close without jeopardizing response times to any type of emergency. For every fire engine company closed, the city would save $7.2 million annually, enough to fund 10 additional ambulance tours each day,” the CBC stated.

Uniformed Fire Officers Association President James Lemonda said in a phone interview that the report’s conclusions were seriously flawed because the authors “lacked a clear and fundamental understanding about the FDNY’s mission, role and core competencies.”

‘Need More Firefighters’

He argued that it was not as simple as saying “since fires are down we will just close firehouses and reallocate those resources into more ambulances on the road.”

“We are a city of 8.6 million and by all indications on the way to nine million, spread out over 302 square miles, including places like Hudson Yards that’s going to be like a city within a city, or Long Island City, where Amazon is going in Queens where there are already a dozen tower cranes in the air building right now,” Mr. Lemonda said. “If anything, we need to be adding engine companies.”

He continued, “Seventeen years ago, two of the world’s tallest buildings were felled in our city, and while dealing with that we provided comprehensive fire protection to the rest of the city. Now we drill for mass-shooter events. Start pulling on the strands that weave this safety net and you undermine it.”

Uniformed Firefighters Association President Gerard Fitzgerald said in a statement, “Right now, New York City’s emergency responders—both EMS and Firefighters—are doing more with fewer resources than ever, and even thinking about slashing their budgets in the current environment would be highly dangerous and irresponsible. We’re not just talking dollars and cents—New Yorkers’ lives are on the line. Our men and women in uniform are stretched as it is.”

Cites Snowstorm Demand

He continued, “During [the Nov. 15] snowstorm, fourth-due engine companies were responding to emergencies, meaning that first-, second- and third-due companies were all being engaged, and response times neared a half-hour to 40 minutes. Systemwide, we’re nearly 28,000 runs higher than we were at this time last year. Response times are increasing due to changes in traffic flow and drastic neighborhood population increases in areas like Hudson Yards and Long Island City, where fire safety infrastructure hasn’t kept pace with new development.”

EMS ‘Churn’ Carries a Price

Dr. Kevin Munjal, a city-based Emergency Medical Service specialist and author, said in a phone interview that the CBC report was “appropriately provocative” in critiquing the status quo, which includes encouraging thousands of experienced FDNY EMS personnel to seek a “promotion” from the medical side of the agency to better-paid firefighter jobs.

He continued, “The CBC report points to so many ways we can use current dollars and realize a greater value. We need to be guided by the triple aims of the Institute for Healthcare Improvement; improved patient outcomes, improved patient experience and lowering costs.”

According to Dr. Munjal, starting in January engine-crew members will be cleared to start offering additional Basic Life Support capabilities, including administering albuterol for asthma, epinephrine for allergic reaction and aspirin for chest pain. (In 2014 FDNY Firefighters and EMS staff were issued naloxone, a heroin overdose antidote.)

“On the one hand, Firefighters will theoretically be able to provide more care that patients will be getting quicker, but on the other it will be administered by less-experienced people,” he said.

EMS Union’s View

Vincent Variale, president of District Council 37’s Local 3621, which represents EMS officers, believes some of the CBC’s data supports his case that the city has been underfunding the EMS side of the Fire Department, but he disagreed with CBC’s conclusion that closing fire companies was part of the remedy.

“The fire side is busy enough to maintain the firehouse footprint we have because when you are talking about protecting this city, it’s not just the traffic and congestion we are dealing with but its vertical nature you have to account for,” he said in a phone interview. “You want a money-saving idea? How about retaining our EMS workforce? The city spends millions on training EMS recruits only to lose them to the fire side. That’s 15 to 20 percent every hiring cycle, to the point that right now 60 percent of our EMS has less than three years on the job.”

Mr. Variale said that there was a growing body of medical research that confirmed a connection between the levels of experience of EMS personnel with improved patient outcome.

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