M E M O R A N D U M

DATE: 8 March 17
TO: City Manager James Grabowski
FROM: Chief Thomas K. Freeman
RE: City of Elmhurst Emergency Medical Services

This memo will serve as an effort to evaluate Emergency Medical Services for the City
of Elmhurst and its Fire Department and determine an acceptable level of providing care
within necessary timeframes to deliver the best patient outcomes.
There is no question that we need to send the proper apparatus to the appropriate call
and whenever possible free up critical vehicles to be available for the next emergency.
In doing so, once one of our two ambulance transports to Elmhurst Hospital we should
have the ability to respond with first responders and deliver immediate lifesaving care.
The question is whether we should do that with Basic Life Support (BLS) or Advanced
Life Support (ALS) non-transport fire apparatus.
It is obvious that we need to continue to blur the lines in the City of Elmhurst so as to
receive the best and most successful cross section of emergency response. For over
four decades the use of contract paramedics has proven to be an efficient and effective
way to deliver Emergency Medical Services (EMS) to those we protect. However, an
increase over time in EMS calls in the City of Elmhurst has created a different set of
service level demands. The increased need to respond to medical calls has created a
much greater need for additional trained paramedics, which is often difficult in a
department of our size.
In the last five years alone we have seen a 15% increase for EMS calls for service while
the corresponding calls for fire service have been relatively flat. (Chart 1) Peak call
volumes in the City of Elmhurst are between the hours of 0700 and 1100 hours dropping
off slightly and peaking again in the early afternoon hours with a final spike occurring
between 1800 and 2000 hours. Additionally, empirical data indicates there is nearly a
65% reduction after 2300 hours in all types of calls in the City of Elmhurst. These
spikes are most predominate Monday through Friday with some semblance occurring on
the weekends as well though not as dramatic (see Chart 2 and 3).
Chart 1

Chart 2

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Chart 3

Elmhurst utilizes DuPage Public Safety Communications (DuComm) as their public

safety dispatch agency for receiving and handling emergency calls. DuComm
processes over 200,000 911 calls a year for service and over 1.1 million phone calls in
and out of the communications center. DuComm is a Mutual Aid Box Alarm System
(MABAS) center for MABAS Division 12 of which we are a member. Relative to the
emergency dispatch methodology for calls for emergency medical service, DuComm
utilizes a process known as Emergency Medical Dispatch (EMD). This is a systematic
program of handling medical calls with trained telecommunicators using locally approved
guidelines that permit them to quickly and properly determine the nature and priority of
the call, dispatch appropriate response and give the caller any instructions that can help
treat the patient prior to EMS arrival.
As far as dispatch of appropriate response, the Elmhurst Fire Department generally
responses to a call for emergency medical service with minimally an ambulance staffed
with two Illinois Department of Public Health (IDPH) certified paramedics. Depending on
the nature of the call and the advice given by the EMD guidecards; a firetruck is
sometimes dispatched along with the medic ambulance. The firetruck could be either a
pumper or aerial ladder truck.
While there are often calls for emergency medical service that can readily be handled
with the two paramedic assigned ambulance there are many that require additional
assistance. The sending of a firetruck to back up the ambulance is often necessitated
for life-threatening emergency incidents, calls that enough reliable information was not
initially received so as to determine the patients condition or if additional lift assistance
is necessitated because of physical condition of patient or location. If the firetruck is not
needed on an incident it can be returned to quarters to await its next emergency.
Normal staffing of personnel is two paramedics assigned to the ambulance and two or
three firefighters assigned to the apparatus.

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It is with that thought in mind that we need to evaluate the premise of merging on-duty
firefighters with the private contract paramedics. While this system has worked for
years, as of late has been scrutinized as to its level of proficiency. Paramedics, in the
State of Illinois, regardless of their employment status are generally highly qualified
caring individuals who do their job and do it well. Additionally, we have a quality
assurance program that validates their performance levels. In the past, as good
stewards of the community, we have had an obligation to curb against rising expenses
and legacy costs and the contract service with Metro Paramedics is one of proven
matter. The return on this investment is undeniable, especially during times of revenue
and budget constraints.
Therefore, there are three basic options we should explore.

Add 3rd Medic Ambulance

The first option for consideration is to contract a third ambulance with two medics. This
unit could be available 12 or 24 hours a day or following a study of peak demand times
(time of day and day of week) be placed under contract for a power shift periods of high
call volume. In the last five years, while we have seen a steady increase in requests for
third and fourth ambulances when our two contract paramedic units are out of service
on calls. On average our contract paramedic units arrive on scene 97% of the time.
Therefore, this has created a corresponding increase in mutual aid ambulance requests
from our neighbors and a corresponding delay in the care and treatment for the patient.
In 2015, mutual aid ambulance response times have averaged 7.38 minutes. Our
outbound mutual aid response time to our neighboring departments is comparable. This
does not include delays in transfer time from DuComm dispatchers to NorComm
agencies. The average response for an Elmhurst medic unit is less than four (4)
minutes in the City. The maximum industry standard is eight (8) minutes.

It should be noted that a replication of comparable services of surrounding communities,

e.g. firefighter/paramedic staffing a third ambulance; would add in excess of $1,000,000
to our existing budget, exclusive of legacy costs. (see Chart 5)
Chart 4
24 Hour 3rd Ambulance With Two Medics
Monthly Annual
$35,292 Year 1 $423,507
$35,645 Year 2 $427,742
$36,001 Year 3 $432,019

Data: Metro Paramedics

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 ALS Non-Transport Assist Apparatus
The second option would be designating fire apparatus as ALS non-transport assist
vehicles. With the daily staffing returning to 14, including the Battalion Chief, we would
have the ability with 13 firefighters, who are also paramedics, to begin a program to staff
one suppression company per station per day. By designating fire apparatus as ALS
non-transport assists, we would have the ability to staff those apparatus only when
paramedics were available. Therefore if we were running short on any particular day
we would not be obligated to hire back a paramedic; however this could provide
inconsistencies in best care to the patients. The vehicle, according to EMS hospital
system rules, would then be BLS on those shift days where we are without sufficient
Elmhurst paramedics from the department side. All other times the on-duty paramedic
would be part of the daily staffing and we would have ALS non-transport apparatus at
both stations. This means there could/would be days (24 hour tours) that a paramedic
fire company would not have a paramedic assigned. These response protocols are
compliant with Illinois Department of Public Health (IDPH) under their administrative
code regulating emergency services in the State of Illinois. Following a meeting with
Elmhurst Hospital, it is anticipated that equipment needed for the ALS assist vehicles
would be provided by them at no cost. This public and private blending of purpose
would enable us to save any cost of implementation and subsequent supply
replacement by using Elmhurst Hospital as our provider hospital. Similar support has
been accomplished throughout the county.
A survey reflects that nearly all the departments in DuPage County and immediately
adjacent Cook County area respond with ALS non-transport vehicles. (Chart 6)
In order to assure a firefighter/paramedic is on duty every shift at each station, an
overtime pay commitment would be required. Without such a commitment, anytime a
scheduled firefighter/paramedic were to call in sick, the apparatus that day would have
to be designated through the system hospital as BLS for that 24 hour period. Very
obviously this raises the issue of consistency in delivery of advanced life support to this
City.
Chart 5

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If this second option is exercised on an available basis, once the ALS apparatus is
properly filed with the system (Good Samaritan Hospital), then a licensed paramedic
must perform to his/her level of certification; this means if a paramedic is on duty and
assigned to that piece of apparatus as part of the daily staffing model, he/she acts as
the paramedic.
Advantages
Provides two additional vehicles to arrive on the scene with or without an ALS
transport ambulance and begin immediate life support care
Provides ALS care in the event the ambulance is not initially dispatched due to
the manner in which a call is received by DuComm and seemingly not in need of
an ambulance response, i.e. carbon monoxide detector, investigation of odor in
home, appliance fire not extended with exposure to byproducts of combustion
(smoke)
Every apparatus and vehicle, whether Fire or EMS, staffed with certified
paramedic ALS/BLS (EFD (but not guaranteed) and/or Metro)
Utilization of long tenured firefighters with existing paramedic skills on fire
apparatus at both stations
Ability to permit paramedics who are trained as firefighters to operate in a hostile
or Immediately Dangerous to Life or Health (IDLH) environment which contract
medics cannot

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 Disadvantages
Great lack of certainty in scheduling; No guarantee of having paramedics on
every shift; would need a commitment from union that every shift would be filled
with a paramedic
Potential future personnel costs due to paramedic certification of firefighters
requirements would necessitate future firefighter eligibility lists to require
paramedic as a prerequisite for hiring, hence potential for increased entry level
salaries and associated benefits
Require existing personnel to obtain paramedic license would require collective
bargaining agreement changes resulting in additional benefits and pension
costs.

Rapid Response ALS Unit

The third option would be a Rapid Response ALS Unit. This would consist of a vehicle
such as a Ford Explorer equipped with necessary ALS equipment and drugs and staffed
by one Metro paramedic. These units are just becoming popular in the State of Illinois
to supplement emergency response as well as prepare for non-emergency service to
the community by way of Mobile Integrated Healthcare and community paramedicine as
a result of the Affordable Care Act.
The cost of one unit with one medic would be $165,352. Two units with two medics
(with one medic each) would be $371,289 or a power shift of less than 24 hours option
with prorated compensation.
This vehicle could provide numerous benefits to the City while supporting and
supplementing the ALS emergency services response of the existing two medic units.
The Rapid Response ALS unit would allow for immediate response to a call for
assistance in the event that both Medic 1 and Medic 2 are committed to emergencies.
This unit would have everything needed to provide immediate life support care and
treatment and be assisted by a responding Elmhurst fire suppression unit. While a
transport ambulance would still be provided by a mutual aid town there would be no
undue delay in the initiation of ALS care. At the point of the arrival of a mutual aid
ambulance, the Rapid Response ALS unit would transfer patient care to the mutual aid
ambulance and then be available in the City of Elmhurst for any subsequent response.
This unique vehicle could be situated at either station and provisions made with
DuComm to move it strategically at any time based on demands for service by existing
paramedic units. It would be dispatched by DuComm with its own unique unit signature
identifier so it is known externally and internally that it is a paramedic assist vehicle not a
transport vehicle (under normal circumstances). This type of response vehicle would
have the unique ability to negotiate through heavy rush hour traffic and other logistical
configurations more expeditiously than a larger piece of fire apparatus. It is anticipated
that this vehicle would be replaced under contract every five years.

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 Advantages
Consistently provides ALS response on all shifts for times when existing two
medic ambulances are not available
Provides ALS response for times when existing two medic ambulances are not
available
Continues operating with ALS provider that is a known commodity
Continues to be cost effective for the City while providing a high level of care
Fulfills the gap in on scene paramedic when existing ambulance are out of
service
Great flexibility on moving between stations in time of need
Can provide efficient movability during peak traffic periods as opposed to larger
apparatus
Can be a touchstone for future enhancements of mobile integrated healthcare
through the Affordable Care Act
Great flexibility during City special events such as Rock The Block, Turkey Trot,
Bootiful Saturday or the St. Patricks Day Parade
City of Elmhurst can pilot the program for a year to measure response times;
have PA&S Committee review at that time and measure success
Disadvantages
Still will be times when the City will count on mutual aid ambulances for
subsequent calls for service
Does not have transport capability
May be called upon to perform on the scene for a brief period of time by
themselves (1 to 3 minutes) as a single paramedic

Conclusion
The future of emergency medical service is well beyond the ambulance rushing to the
scene. Our delivery should have a patient desired focus with an emphasis on public-
private collaboration and multi-stakeholder partnerships as defined by local needs and
the resources of the City of Elmhurst. The continuum of care must include our existing
structure with the contract paramedics but also allow the EMS system to expand and
break down the silos that often result in an ineffective response.
Our EMS emergency response is one the most essential public safety functions. Fire
service based medical service systems must be strategically positioned to deliver critical
response and effective patient care. We must create a response infrastructure that
meets the routine and anticipates the catastrophic emergency needs of our city on a
daily basis.

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 Proposal Program Start Cost
1 Additional 3rd medic +3-5 months $423,507
unit with 6 medics
(year 1)
2 ALS fire companies +3 months <$75,000*
one (1) each at St
#1 and St #2
3 ALS Rapid +3 months
Response unit
1 unit w/1 medic
$165,352
2 units w/2 medics
$371,289
(1 medic each)

*Long term pension implications have not been calculated