Emergency Medical Services
Assistant Chief David Almaguer
832-394-6800
600 Jefferson, Ste. 800
Houston, Texas 77002
david.almaguer@houstontx.gov

Since 1838, the Houston Fire Department has provided high quality fire service to its citizens. In 1971 the Houston Fire Department began providing the citizens of Houston with quality emergency medical care. High quality emergency medical care is not defined solely in terms of life saving interventions for critically ill or injured patients. High quality emergency medical care is defined by the decisions made on each and every patient encounter. The challenge EMS providers face is to make important, sometimes critical decisions with a limited amount of information. Other times Houston Fire Department personnel are called upon solely for their opinion as EMS professionals.

The highly educated EMS personnel of the Houston Fire Department pursue excellence in their profession by combining the benefits of medical science with the art of compassionate care. In all cases, potential patients are approached with the greatest professionalism and concern for their well being.

Overview and Demographics
The City of Houston is a six-hundred plus square mile area spread out over a 1000 square mile region in Southeast Texas. It has a night-time population of nearly two million people and over three million daytime population. One out of every ten citizens utilize EMS. Each year there are over 200,000 EMS incidents involving over 225,000 patients or potential patients. On the average, EMS responds to a citizen every 3 minutes. Each EMS response is made by one of 88 City of Houston EMS vehicles. Thirty seven of these are staffed by two paramedics and provide Advanced Life Support (ALS) capabilities. These consist of fifteen ALS Squads, and twenty-two ALS transport units with eight functioning in a "Dual" capacity as both ALS or BLS. The remaining fifty-one transport units are Basic Life Support (BLS), and staffed by two Emergency Medical Technicians.

Personnel Staffing
The EMS program is integrated into and administered through the over 3900 member Houston Fire Department (HFD). As a result, all EMS personnel are also fire fighters experienced in emergency rescue, extrication, and the suppression and confinement of hazardous materials. All fire fighters are specifically trained and annually re-trained in basic first responder (FR) activities. All new cadets in the fire department since 1981 have also been EMT trained.

There are over 2,000 state certified EMTs available to staff the 51 BLS units. This is an adequate supply of EMTs to meet current and projected needs for BLS staffing. Furthermore, the future supply of EMTs is ensured by the departmental requirement that all new cadets hired receive EMT training.

There are approximately 300 paramedics currently assigned to ALS units. This figure does not include EMS supervisors. The department's goal is to staff two paramedics on all ALS units and maintain a sufficient reserve pool to accommodate staffing and training requirements.

One step to achieve this goal began in April 1996. During fiscal years 97 & 98, three Fire Training Academy Cadet classes were trained as paramedics upon completion of their fire suppression training. The positive impact of this training was felt departmentally in March 1999.

Ambulance Placement
To properly serve the city, ambulance units must be located in a manner that best services all the residents of the city. The location of ambulances is based on the concept of fractal, rather than average response times. Measuring the response time of all sectors of the city derives the fractal response time. Our goal is to have a first responder or BLS on-scene in less than four minutes and an ALS on-scene in less than eight minutes on 90% of all calls.

To ensure quality care to all sections of the city, each unit is located where it can respond predominantly in its defined territory and can arrive at an emergency within the fractal time frames established by the system based on an area's need for emergency service. One territory may have three units to serve its high call volume and another territory may have one unit to serve its low call volume. Both territories, however, have the same response time goals.

In an effort to minimize the response time to citizen's emergency calls, we implemented a "Squad" program in the 2001. A Squad consists of two paramedics, usually in a suburban or other vehicle, that respond to an incident to administer advanced care. If they are not needed to actually transport the patient, once a BLS unit has arrived, the BLS unit can take the patient to the hospital and the Squad can return to service ready to provide additional care to citizens.

The Demand for Emergency Medical Service
The public's demand for emergency medical services has steadily increased over the last eleven years from 137,561 EMS incidents in FY91 to 214,341 in FY01. This demand can be defined by the following workload measures.

Incidents represent the demand for emergency services by the public, while transports represent the resources deployed to satisfy the public's demand for emergency services. To aid with its growing demand for service the Houston Fire Department has enhanced its medical priority dispatch system and has implemented the First Responder program.

Medical Priority Dispatch
Emergency medical dispatchers (EMD), using the computer-assisted medical priority dispatch system, interrogate callers in order to determine the location, nature, and priority of the medical emergency. This information is then utilized to identify and dispatch the closest available appropriate EMS response units (First Responder, BLS ambulance, ALS ambulance, or Paramedic Squad). EMD's can also use pre-arrival instructions to provide critical dispatch life support instructions over the telephone until EMS units arrive on scene.

First Responder
When the response time for an ambulance unit is delayed, or when a probable critical situation exists, nearby engine or ladder trucks are dispatched simultaneously to initiate BLS as needed or to provide BLS support for the ambulance crew. The First Responder responds to certain emergency types where there is a low probability that a patient transport will occur. Under these circumstances the First Responder is dispatched to a call in lieu of an ambulance unit, saving the ambulance for another, possibly more emergent call. Due to the new expanded patient care role, it has become even more important that engine and ladder companies be consistently staffed with a minimum of four fire fighters. Currently, the department operates 116 First Responder apparatus.

EMS Performance Measures
To help track the quality and effectiveness of the emergency medical service system the department monitors the survival rates of cardiac arrest of its patients transported via HFD. Response times are often misused or misinterpreted as they are only a crude measure of the system. Clinical outcomes such as cardiac arrest survival rates are a more accurate indicator of performance. The importance of response time for first responder units is demonstrated in HFD data that directly correlates response time to cardiac arrest survival as shown in the table below.

Although the overall cardiac arrest survival rate is often referred to as a quality indicator, EMS professionals use witnessed Ventricular Fibrillation (VF) survival rates as a standard.

Currently, HFD EMS is developing a continuous comprehensive evaluation program, which will assess all aspects of the EMS system. This program will include evaluation of structural, process and outcome measures. In addition to survival, other outcomes such as disease, disability, discomfort, dissatisfaction, and destitution could be utilized for evaluation. This enables appreciation of the complete spectrum of EMS effects for the community.

Administration

The City of Houston EMS Medical Director is responsible for all medical aspects of prehospital patient care. The Medical Director has the authority to approve the level of prehospital care which may be rendered by each of the departments members, establish and monitor compliance with field performance guidelines and establish and monitor training standards. A staff of four physicians provides on-line and/or on-scene medical direction for all critical patients 24 hours per day. EMS nurses assist in the development and revision of protocols, medical standing orders, continuing education programs and addressing equipment and legislative issues.

An Assistant Chief heads the EMS administrative staff with the direct assistance of the District Chief for EMS. These two individuals in essence are the executive classified arm of EMS operations. They are responsible for the implementation of the operational structure- EMS staffing assignments; disciplinary action; complaint disposition; fiscal management; and compliance with all bulletins, orders, policy and procedures. An administrative support staff of approximately 30 people execute these functions.