If we’re lucky, we learn our most important lessons from the mistakes of others. You’re socializing with off-going crews in your agency’s dayroom when someone reaches over your partner Bud’s shoulder.

“Here,” she says. “This was in yesterday’s mail.”

Bud notes the return address, and his conversation ceases mid-sentence. The room goes quiet as he slits the envelope and unfolds a one-page letter. He’s still reading it when your supervisor enters the room and invites both of you into an adjoining classroom. The expression on her face is serious. There’s a similar letter for you, and she hands it to you as you each take a seat.

The letter is from your agency’s attorney. Your agency has been named in a lawsuit as a result of a vehicle failure several months ago, and the attorney wants to meet with you both. Your ambulance ran out of fuel on the way to a cardiac arrest, and a patient subsequently died. The call came in an hour after shift change, while you and Bud were having coffee with another crew. Bud received a written warning at the time of the call for falsifying the unit’s fuel level on your morning checklist. Even then, he had a reputation for pencil-whipping his documentation.

You’ve been expecting this letter. But now, reading the terse legal language, you feel a distinct prickly sensation at the back of your neck. Lots of people are being blamed for this person’s wrongful death, including Bud, you, your supervisor, your education coordinator and your ops manager. But especially Bud. And you.

This was Bud’s fault, pure and simple. He was the driver that day. I checked the patient compartment and Bud checked the mechanical systems. We take turns; that’s how it works. Not only that, but very few people survive cardiac arrests. We both felt bad after this call, but we didn’t cause the cardiac arrest. I don’t think it’s fair. Why should we be blamed for the person’s outcome?

You sounded about right there for a moment, until you brought up the patient’s survivability. It wasn’t the patient’s duty to survive. It was your duty to help, and due to issues that were under your control, that didn’t happen. Now this thing is in the hands of attorneys, and you’ve left it to someone else to decide who’s culpable and who’s not. I think you’re in trouble.

How is it my fault? I checked my part of the ambulance. I always do.

I’m no attorney, but I think we’re all responsible for what we know. You’re a trained observer. When you realize your partner has checked the mechanical systems without opening the hood, you’re responsible for that information. When you sit down at a coffee shop 10 minutes after clocking in, you know what kind of checklist you’ve done. And when you sign the checklist and see that your partner has just drawn lines through the sections that pertain to the mechanical systems, you’re responsible for your own doubts, too. Let’s face it: You’ve trusted your luck for some time now. You know better than that.

What am I supposed to do? I’m not Bud’s supervisor. I have enough trouble doing my own job without being responsible for his too. Besides, Bud’s a nice guy. I’m sure as hell not going to run to a supervisor and rat on him every time he screws up. Who wants to work in that kind of environment?

You’re right, of course. On the other hand, your ambulance can either earn you a living or kill you, any day of your career. To be blunt, Bud is not your friend. He’s a slug. He cheats. He’s knowingly risked your life, your future, your family’s welfare, your agency’s financial resources, the good names of your colleagues and the lives of others rather than doing his job. And you’re enabling him to go right on doing it. If that doesn’t bother you, it should. And if it bothers you but you’re ignoring it, maybe you shouldn’t be surprised when somebody steps in and shakes you up some. Face it, that’s what attorneys do.

Like aircraft, ambulances consist of mechanical, electrical, hydraulic and structural systems. Every one of those systems is destined to fail eventually, and it’s your job to stay aware of yours every minute of every day.

See, your morning coffee is this whole other thing.

Thom Dick has been involved in EMS for 40 years, 23 of them as a full-time EMT and paramedic in San Diego County. He is the quality care coordinator for Platte Valley Ambulance Service, a community-owned, hospital-based 9-1-1 provider in Brighton, CO. Thom is also a member of the EMS World editorial advisory board. E-mail boxcar_414@yahoo.com.

EMS on a Budget

Alternative drug packaging & inventory control ideas that save money

As EMS managers continue to look for ways to tighten budgets, some are returning to past practices as a way to trim a few dollars. East Pierce Fire and Rescue in Bonney Lake, Wash., is going back to using vials for some infrequently used drugs. “While there is a convenience factor for non-time critical calls, we found that there’s no negative effect to patient care, and it’s considerably cheaper,” says East Pierce Battalion Chief and Medical Services Officer Jeff Moore. “The question we need to ask is, ‘What do we need to be carrying?’”

The first drug Moore says they reviewed was adenosine, a drug their system is required to carry, but is seldom used. The district is switching from pre-loaded 6 mg and 12 mg syringes to vials with the same doses. The retail price for a 12 mg adenosine syringe can be as much as $104 each, vs. a 12 mg vial priced at $38. The paramedics will use plastic Luer-lock vial adapters to decrease the risk of an accidental needle stick. “There is no actual sharp needle used anywhere,” he says.

East Pierce is also taking advantage of new Washington state regulations allowing EMTs to draw up epinephrine and administer it IM to patients in anaphylactic shock. This will allow the department to stop purchasing expensive epinephrine auto-injector pens and switch to vials.

The retail price for a set of adult and pediatric auto-injector pens is now close to $210, Moore says. Each has a maximum shelf life of 18–24 months. Instead, East Pierce can purchase a 1 mg vial ampule for $2.58, plus a syringe with a safe needle for $.50. The fire district is able to stock each unit with a BLS kit that includes a 1:1000 vial for less than $5.
 

Some training was required, but Moore says it has been relatively easy. In Washington, EMS agencies developed comprehensive online and PowerPoint training programs that were shared, helping to keep the cost of the training to a minimum. Individual medical directors make the final decision whether to stay with the auto-injector pens or use the vials.
 

“The risk of accidental overdose is minimized by having the EMTs use a 1 cubic centimeter (cc) syringe to draw up the epinephrine from a 1 mm vial, instead of using a multi-dose vial,” Moore says. The problem is that 1 mm of epinephrine is packaged and sold only in a glass ampule. “To avoid the hassles of dealing with a glass ampule, we found that we could order epinephrine in 1 mm vials under the trade name 1:1000 adrenaline. We are now checking to make sure it’s pharmacologically the same,” he says.
 

The fire district is also reviewing whether to switch from nitroglycerin spray, at $209 per 60 meter dose bottle, to nitro tablets at $19.79 for a bottle of 100. While Moore admits, nitro tablets aren’t appropriate for every patient, for most the tablets are an acceptable alternative.
 

Switching from the more convenient preloaded syringes may not be a big deal for a small department, but a large department or a more rural service with a low call volume and numerous BLS and ALS apparatus spread over a large area, could see significant savings given a medication’s shelf life and how often it’s used.
 

East Pierce is a combination career and volunteer department that runs approximately 6,500 EMS calls per year from 14 stations. Including reserve vehicles, Moore says there are 18 ALS and more than 20 BLS apparatus that carry EMS supplies. “Making these switches could save us upward of $15,000 per year, approximately 15% of the supply budget,” he says.

“Those are dollars we can apply somewhere else.”
 

He recommends checking with suppliers to look at options and shopping around. “It’s amazing how much variability in cost there is between vendors. We found some vendors charging double for the very same product,” he says.
 

Better inventory control has also helped to keep costs in line. Since the district went to electronic patient contact records (ePCR) a little over a year ago, Moore says that tracking medications has become much easier. For example, he is able to generate a report that documents how much adenosine was used compared to how much was ordered per year.
 

“We found that we were ordering 80–90 units per year, but only using 14. Almost 90% of what we ordered was expiring,” he says. “The ePCR helped us improve just-in-time ordering and delivery. We were finding we were throwing away too much.”

Inventory control
Graham (Wash.) Fire and Rescue realized a significant savings when it switched to an off-the-shelf, computer-based, online inventory control system and customized it to fit a new supply philosophy. Instead of managing for “what if,” the department stocks medical supplies based on actual patient transports, saving time and money. “I know ‘what is’ and I plan for ‘what is,’” says Graham Assistant Chief of Medical Services Todd Jensen.
 

Graham Fire and Rescue serves approximately 72,000 citizens living in a 75-square-mile area south of Seattle. Jensen says the department average 12 patient contacts per day. Six of those turn into transports.
 

Graham uses AmbuTrak Inventory, Asset and Fleet Management software, a subscription service that costs the department $1 per day, per unit— whether that’s a medic unit or station. It inventories all hard and soft goods, from stretchers to glucagon. The system also notifies him when equipment is in need of scheduled maintenance.
 

Jensen says his goal was to implement a system that mimics the way the crews were already conducting rig checks. He wanted to identify what supplies he was buying under his EMS budget, when he was receiving them and where they were going.
 

Previously, the crews used paper checksheets for rig checks that Jensen had to manually review. “We used a flood-the- system approach,” Jensen says. “That system works well, but it’s not very efficient.” The new system is tied into the electronic patient care reports. Paper checksheets were replaced with an online form.
 

It took a year to implement the new system, but within the first seven months. Jensen says he noticed some trends he hadn’t seen before. He noted that the crews were going through about four times as many IV catheters as IV fluids. “Either my people were really bad at IVs or we were supplying a whole other agency,” he says. It turned out that neither was the case. “We were just throwing a lot away,” he says.
 

Under the new system, inventory is marked as it arrives. A notation indicates where it is stored. Usage is tracked on a weekly basis. But instead of tracking every 4×4 or pair of gloves, Jensen developed a system he calls, “Box Plus.” In this system, the medic unit is its own supply room, eliminating the need for a central supply. Weekly rig checks monitor the number of unopened, full boxes of supplies on the rig. Only unopened, full boxes are replaced.
 

At the start of the day, the crew hits a button on the online AmbuTrak system to view the supplies on the rig. Instead of going through the medications and looking at every expiration date, the system automatically alerts the crews if a drug is coming up on its expiration date or has expired.
Although it’s efficient, Jensen admits that it wasn’t an easy shift. “A big culture change had to take place,” he says.
 

The savings, however, were substantial. Jensen says that he went from approximately $64,000 of supplies on hand to around $31,000. “And we aren’t having things expire on the shelf. That’s the real benefit,” he says.
Another benefit is that, as a manager, Jensen can see specifically where the product is going. By expanding the report, he can see which patient received which drugs and supplies. He uses this information to prepare a weekly report for staff meetings to show the total usage of a product by unit, making supply adjustments as needed.
 

The new system helps maintain a level of standardization that has been difficult in the past. “As hard as you try to standardize a fleet, people do certain things and the rigs begin to morph,” he says. Now, even if a crew overstocks a certain item or moves it to a different location, everything gets put back in place on Monday. “It evens out and stays that way over time,” Jensen says.
 

There were initial concerns about having enough space on the rigs for the extra supplies, but Jensen says that it turned out not to be a problem. “By only stocking what was needed, we ended up with more space on the rigs,” he says. “The lesson is that we’re all running around with more than a week’s worth of supplies.”

TransCare Ambulance Services of the Crisis Center of Tampa Bay improves operational efficiency and increases patient transports.

The Challenge
TransCare Ambulance Services, a division of the Crisis Center of Tampa Bay, serves more than one million citizens of Tampa Bay, Florida. With more than 3,000 calls per day and 1,900 transports per month, TransCare needed to operate as efficiently as possible to provide optimal patient care in the community.

TransCare’s inventory restocking process was taking valuable time away from its ambulance crews. If crews could decrease “start of shift” time, they could establish more efficiency and less down time. Through internal reviews, TransCare observed that crews made two to three trips in and out of central supply to restock their ambulance. This practice took approximately 25 to 30 minutes. TransCare management wanted to identify a solution that could help them cost-efficiently restock their trucks and save valuable time so that crews could service more calls and transports in the time saved.

The Solution
TransCare decided to implement AmbuTrak, a Web-based inventory management system designed specifically for EMS providers.  AmbuTrak provided the tools that TransCare needed to efficiently manage operations and establish accountability with crews and Material Management staff.  TransCare management sealed all of the cabinets in their ambulances and trained the crews to use their bags as much as possible. The new process cut down inventory checking time. With AmbuTrak access on their laptops, crews were able to complete their vehicle inspections on the trucks during their calls in “real time” and send the supply requests proactively. When they returned to central supply, they could make one trip and get all of their stock.

TransCare immediately realized savings in budgeted supply dollars, allowing the organization to hire staff to perform vehicle checks for the crews. Now, when the crews come in to restock, their inventory needs are ready in pre-loaded, sealed kits.

Bottom-Line Results
AmbuTrak helped TransCare achieve significant results that not only addressed patient care needs, but also increased operational savings and billable transports. Prior to implementing AmbuTrak, TransCare performed approximately 1,900 transports per month. Now, with the same supply budget and staffing, TransCare is transporting approximately 2,300 patients per month.

Visit any Fire Department or EMS Agency in the country and there is a good chance you will find very limited accountability and control over the agencies medical supplies and company assets.  This is not without great effort as all agencies have processes in place to ensure they have ample supply on hand, that vehicles are ready for service and company assets are accounted for and in working condition.  The problem agencies are finding are these processes are archaic, managed with paper check sheets  and logs, and lack report tools to facilitate decision making.  As a result, agencies have real problems managing their inventory and holding employees and volunteers accountable for their role in the process. 

Realizing this growing need, EMS Technology Solutions has spent the last 3 years working with Fire Departments and EMS Agencies to develop the first inventory and asset management tool kit designed specifically for the Fire and EMS market.  Ambutrak is now in use across the country helping agencies control their inventory costs, reduce service interruptions and drive accountability.  It has been called “a god send” and the “best thing to hit EMS since the defibrillator”.  With so many happy customers it is certainly noteworthy to see what makes Ambutrak different from retail and warehouse inventory tools and how it is helping Fire Departments and EMS Agencies make strides in their business.

To start with Ambutrak was designed from the beginning specifically around the processes in place at Fire Departments and EMS Agencies today.  Therefore you can easily implement Ambutrak with minimal process change. 

Supply Managers whether they are full time, or volunteer are saving time and reducing inventory costs by using Ambutrak.  It helps them know how much inventory they have on their shelves, what the average usage is for a given period of time and what to order to maintain appropriate supply levels.  Ambutrak even helps supply managers create purchase orders based on predetermined reorder points and PAR levels.  These purchase orders can easily been sent to suppliers and used when receiving shipments for added accuracy.   Ambutrak also gives the supply manager insight in to the inventory in outlying stations and on service vehicles.  This allows them to identify expiring medications, locate equipment in need of service and fill supply requests to ensure the agency is ready for service. 

EMTs and Paramedics use Ambutrak to perform station and vehicle inspections.  The inspection process enables them to verify inventory levels and make supply requisitions to supply rooms for fulfillment.  They can report on the maintenance condition of stations and vehicles while providing notification of areas that are in need of service directly to supervisors.  For agencies using electronic patient care reporting, Ambutrak can also capture and report on the supplies used in administering care.  Since all actions taken by crew members are recorded with a name and a time stamp Ambutrak provides unsurpassed accountability.

Operations Managers love the benefits that an electronic inventory and asset management tool provides.  With Ambutrak’s reporting engine, managers can easily see how much inventory is currently on hand and review usage patterns down to the individual item or crew member.  They can quickly identify service issues with vehicles, equipment and monitor the expiration dates on medications.  Since Ambutrak provides for report scheduling they can do all their monitoring without having to login and retrieve their data.  Once scheduled, key reports are conveniently delivered to their email inbox for review.  This is also a great feature for agencies that want to repurpose data collected for other functions such as accounting or scheduling of service calls with third party vendors.  All of which provides greater accountability and control while reducing ordering costs, inventory costs and service interruptions.

Since Ambutrak’s software is provided as a service, IT Managers are not burdened with the cost and maintenance of expensive servers.  And since Ambutrak is web based they don’t have to install costly software on individual computers.  It also makes the deployment scalable from a small Fire Department to a large EMS Agency with hundreds of ambulances. 

If you are interested in learning more about Ambutrak you can schedule an online demonstration by going to www.ambutrak.com or calling 877-217-3707.

Legal News for Georgia Medical Malpractice Attorneys. State inspections revealed that a couple of EMS vehicles carried expired medications.

Georgia medical malpractice lawyer alerts- Certain county paramedics face corrective action in connection with expired drugs on board ambulances.

DeKalb County, GA (News)—State inspections conducted on emergency medical services (EMS) vehicles in DeKalb County, Georgia, revealed a couple ambulances had expired drugs on board. Paramedics use these drugs as a means of increasing the chances of saving lives under dangerous circumstances, and while these drugs will not necessarily go bad immediately, taking the chance could cost someone their life, according to news coverage posted on Tuesday March 9, 2010. CBS Atlanta acquired documents regarding the use of some expired drugs found aboard certain EMS vehicles, which clearly demonstrated the need for strict adherence to safety procedures.

Documents concerning the troubling news noted that some of the expired drugs discovered on the ambulances included EpiPin, used in treating patients suffering from severe allergic reactions, and calcium chloride, used to “jump-start a heart”. Though most of the drugs carried on emergency vehicles will not go bad immediately, chancing the potency or effectiveness of such life-saving drugs shouldn’t be an option, according to Director of Georgia Poison Control, Dr. Gaylor Lopez. Reports noted that a total of nine expired drugs were discovered aboard one Dekalb County emergency vehicle, while two expired medications were found on another. Reports also noted that DeKalb County paramedics are obligated to verify that no medications onboard emergency transport vehicles exceed expiration dates. Drugs are supposed to be checked on the first day of every month as well as on a daily basis before responding to a call. Corrective measures were expected to be taken against the employees who failed to comply with safety procedures, which require the replacement of old drugs with new ones.

Legal News Reporter: Sandra Quinlan- Legal News for Georgia Medical Malpractice Lawyers.

SOURCE: December 2008, Jems Connect

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About eCore Software – eCore Software Inc. has been a leading provider of HR management and scheduling solutions for Public Service industry operations such as EMS companies, fire departments, hospitals and police departments since 1998.

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Most EMS agencies only realize what their expenses are when it comes to inventory. Out of necessity many EMS agencies are now being forced to do what other industries have done for years, “provide more with less”. By implementing LEAN manufacturing processes coupled with electronic inventory software management, agencies are seeing 40-50% decreases in inventory costs.

One of the leaders in providing an EMS specific inventory management software solution is EMS Technology Solutions (ETS). ETS was contracted in 2005 to build a customized solution for Puckett EMS, based in Austell, Georgia. In 2007, ETS released AmbuTRAK, a web based inventory management solution designed for Fire and EMS agencies. “Puckett EMS started getting calls from other agencies that wanted a solution that would work for them and was affordable to use, so we started working on a web based solution that met the needs of what agencies needed”, says ETS President Shane Garrison, “I think the thing that appeals to most users of the AmbuTrak solution is that it’s so easy to use. As a general rule, inventory software has always been really difficult to manage and very expensive to implement. For most EMS agencies they can’t afford to spend thousands of dollars on expensive software and hardware and smaller agencies never could afford the implementation cost. That’s the beauty of AmbuTrak, because its web-based software, most people already have the hardware that they need. The software is based off of the total number of licenses you require. Our smallest customer has 3 ambulances and our largest customer has 110 ambulances.”

Since the first software license sold back in 2007, not one customer has been lost. They have over 800 licenses and forecast a double in size for 2009. “We are fanatical about the service we provide our customers. Our technical support team is amazing, they know how important each and every customer is and they go out of their way to make sure that they are happy with the software. I make sure each customer has my direct line and cell phone number, if they don’t feel like they’re being taken care of by our support team; I want them to know that they can always call me directly and I’ll make sure that they are taken care of.”

Besides providing a robust supply room management feature that includes bar code scanning and purchase order management, AmbuTRAK also provides a Fixed Asset Manager and a Check In-Check Out Manager. “We provide much more than just standard warehouse inventory management software”, says Garrison, “AmbuTRAK provides solutions that are common for this specific industry. Our customers shape the software based on what they need, their feedback is critical to making sure we’re always on the cutting edge.”

Since they started selling the AmbuTrak solution, ETS has never required any of its customers to sign an upfront payment schedule. Customers pay as they go each month. Their philosophy is that if they are providing quality software, coupled with great customer service and affordable prices, customers will stay.

- Shane Garrison, Vice-President, Puckett EMS